Thursday, 21 June 2012

The rocky road to expertise

In the BMJ this week, Daniel Sokol talks about the role of empathy and compares it with imperturbability (http://www.bmj.com/content/344/bmj.e3980 ), suggesting that overt demonstrations of empathy can alienate patients, and that what they want and need from us is for us to be detached, professional and expert.

I can see his point: who wants a doctor who can't maintain their composure at your time of need? But I think the distinction between empathy and imperturbability creates a false dichotomy. They do not lie at either end of the same spectrum.

It is always nice to be the person who keeps their head when all those around are losing there's, but it can be really difficult to predict who that will be, and it is not always the same person.

Loss of control in stressful situations results from a number of different factors, not all of them directly related to the situation itself. The outcome of each challenge we launch ourselves into will be influenced by the state we are in when we set off. People seem to struggle the most with stressful situations at work when the particular situation itself is one that is unfamiliar to them.

It is easy to persuade yourself that at any one time, we have the competence to deal with challenges up to a certain level, and that it is with further experience and learning that we are able to take on the bigger ones. However, significant stress becomes much easier to manage when you are familiar with the type of stress on offer. And when the stress become familiar, you can stop worrying about how the situation is going to affect you, because you already know, and can start worrying about the other people involved.

For example, breaking bad news, or leading cardiac arrest calls are objectively stressful situations, but they are ones that I do not mind doing, because I am familiar with how the scenarios play out, and how I respond, having had the experience of doing them many times.

Of course, there is no shortcut to experience, and you cannot always know how you will perform in a new situation. The transition from knowledge to expertise is one we do variably well in medicine. That is, we sometimes tutor people brilliantly, and we often do it badly. But with a system of graded and supervised exposure, it is possible to help people learn how to apply their technical knowledge in what are often highly emotive circumstances. The old-fashioned way of doing this is to throw the trainee in, and let them do it badly, until they figure out how to do it well. But that hardly seems fair to the patient.

The more experience one has in medicine, the fewer episodes you face when you do not know what to do. Uncertainty of action, and uncertainty of the possibilities is a significant source of anxiety for junior doctors. However well prepared they are, they often worry about the emotional impact and responses that their words and actions will have on patients and their relatives.

When my junior colleagues ask me how to deal with emotional and stressful situations, I encourage them to be themselves, and to respond in their own style to the emotional needs that they identify in front of them. Being a good doctor does not involve mimicking some model of the perfect doctor, or being ice cool and aloof.


The mark of a good doctor is someone who has achieved expertise in the knowledge and techniques that their specialty requires, but manage to marry this successfully with being natural, being sincere, and responding in their own way to the needs of the patient in front of them.

Few things are more alienating to patients than false affect, and trying to be imperturbable all the time smacks of falsehood and fakery. The simple truth is that sometimes you will be the one who excels, and sometimes it will be someone else. It doesn't always have to be you.

The challenges of being a doctor are varied, and often demanding. To pretend that you can always operate on the same level is to deceive yourself. You will have good days and bad days, and what it is important is to recognise that this does not represent any great failing in you - it is the beauty of the human condition. Forgive yourself, and nurture an environment around you that allows others to take on strain when you are not up to it, and vice versa.

And if you can do that, then you will definitely have a happy and successful career.

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