Cultural Diversity: Walking the Biomedical Tightrope (Reflection on Simpson III)

For the last 12 months I have been fortunate to teach an inspiring and enthusiastic cohort of medical students how to be doctors in the NHS. During this time I noticed how medical curricula are entrenched in reductionist, evidence-based medicine with little space for reflection on what it means to traverse the tightrope Simpson identifies in his piece. The notion of a holistic approach to medicine is only addressed on occasion, for example when covering the so called “softer” skills, such as discussing end of life care. Yet, if we don’t make an active choice to walk the tightrope and make everyday encounters more reflective of the human experience for both doctors and patients, I fear we miss the opportunity to strengthen therapeutic relationships in ways that are beneficial to both parties. As a white, female doctor from a working-class background, Simpson’s piece invited me to reflect on my own clinical and teaching practices. Here, I consider how these are influenced by my lived experiences, and how my patients and students are affected in their own way.

I often say to medical students, that ‘for you it might just be another day at work but for the patient this event is likely to be a huge milestone in their life, so always approach them with empathy and compassion’. However, I think this is only half the story, as often those patient milestones leave a mark on us too. As I walk into my kitchen I see a framed poem I was gifted by a patient and I am reminded of them, their experience of postnatal depression and the dark cloud that accompanied them into the consulting room. During her appointments we ventured into that cloud together and the experience stayed with me for a while.  It reminded of my own mental health challenges and those of my family. Her dark cloud slowly dissipated over the next few months. Similarly, when someone mentions COVID, I am often taken back to a patient who died and how, with their partner, we cried together over the phone, both feeling deeply the injustice of the pandemic. Yet, relating these experiences goes against an unspoken consensus within medical practice that discourages us from showing this side of ourselves, in the name of professionalism and to uphold the precarious perception of doctors as infallible and omniscient. In the context of Covid-19 this has been taken a step further with us being labelled ‘heroes’, a façade that may actually be damaging to the patient doctor-relationship. As Simpson notes: “this relationship builds on the interaction between two people and develops in accordance with the intellectual and emotional capacities of each”. In removing the emotional capacities of the doctor and their humanity we lose an important piece of a therapeutic relationship; without these capacities how can we empathise and communicate effectively? Moreover, there is potential harm to doctors when they are discouraged from being themselves in the consultation room and other aspects of clinical practice. They too have their stories.

The healthiest patient-doctor relationships I have developed are when I have shared part of myself and my story with a patient, which is to say, when I have been vulnerable. Being vulnerable and the kind of empathy this makes possible is not dependent on having exactly the same experience as the patient, but being able to connect and understand across difference. The benefits of this in my experience are two-fold. First, it allows me to demonstrate empathy more sincerely. As clinicians we often find ourselves robotically offering sympathy using phrases such as “I am sorry to hear this” or “that must be so hard for you”. Empathy with sincerity is much more comforting to the patient, allowing me to offer consolation and a route to emotional, and not just somatic, healing. In turn, this often encourages patients to open up further, disclosing information they otherwise might not have shared. Indeed, without a person there cannot be a person-centred relationship. Secondly, being vulnerable and sharing my story allows me to be myself during the working hours of my week. When I have not allowed myself to be vulnerable or feel the emotional pressures that come with routine patient-doctor interactions, I suffer burnout. Sharing my personal experiences with depression and my frustrations with the pandemic – without reframing the interactions to be centred on myself – has on occasion strengthened my relationships with patients. Such interactions increased my resilience because I felt a deeper and more rewarding sense of connection and I felt my patients benefited too. The current medical model and NHS structure does not encourage this approach. This is perhaps in part due to a tradition which works to protect doctors and the prestigious institution of medicine.  However, it might also be because doctors are people too and to recognise them as being vulnerable is challenging!

To suggest that doctors should present themselves to their patients as ‘human’ and as individuals each with a unique backstory is rather obvious. Simpson articulates the point clearly but there is another set of questions that follow from his tightrope walking analogy. To pursue the analogy a step further, we must get the balance right, that is, of sharing enough of ourselves to facilitate the patient-doctor relationship, but not so much that the consultation is no longer patient-centred or that transference occurs. This is perhaps why the practice Simpson refers to was divided regarding the image of the Madonna in the consultation room; although no space is truly secular in a multi-cultural society, an overt expression of oneself could ostracise some patients, damaging the patient-doctor relationship.

As a profession we need to explore this idea more readily to find strategies needed to achieve this balance. We need a cultural shift within medical education to embrace our own vulnerability within our person-centred profession. This process might start by encouraging medical students and doctors to reflect on who they are and how to walk the tightrope. To embrace what they can bring to the table to benefit each individual patient through empathy and compassion. For example, at the beginning of communication skills sessions students could spend time reflecting on their experiences, considering those that may be similar to the experiences of the patients in the session. Or having formal, individual reflective sessions with a tutor throughout medical school. In doing this we also need better support systems for students and doctors to allow us to work through our vulnerability in a supportive and protective environment. For example, tutors or supervisors who have time to help us process our experiences and reflect with us, group sessions for discussing difficult cases and emotions, and more formal, accessible psychological support when needed. We need to do this for the sake of ourselves, our patients and the future of the NHS.

Dr Amy Belfield (she/her) is currently a Specialist Registrar in Infectious Diseases and Microbiology in the North East. She has recently completed a year as a medical education teaching fellow and achieved the PG Cert in medical education, an experience she reflects on in this piece. Follow Amy on Twitter @DrAmyBelfield.