Personal View: The P value of empathy
Authors: Craig Watson
Journal: BMJ (2005)

Just after the beginning of the millennium I contemplate another new contract, a continuing recruitment crisis, and an uncertain future. Some commentators would have me believe that the role of the community physician is not as timeless as I had thought. I am challenged to redefine my role—as a specialist generalist and an expert in multiple pathology—or face extinction at the hands of an army of nurse practitioners who are more adept (and less expensive) at following evidence based protocols. However, my patients have other ideas. Their demand for the attention of their community physician threatens to overwhelm my duty doctor system, my appointment system, my coping strategies, and my morale.

I may defend my professional status by claiming ownership of an advanced body of knowledge or science. But then I reflect that much of the knowledge acquired by doctors is deemed redundant a few years after they qualify and that much of the past and current medical literature is considered to be of dubious validity, falling foul of rigorous statistical analysis. What doctor would stake their professional status on so much shifting sand? And how do I defend my professional income? Within a few months of the introduction of the new GP contract, debate rages about the validity and relevance of its standards on chronic disease management and plans are already afoot to revise them. Most health boards claim to have insufficient funds to pay for the locally or nationally enhanced services that GPs with special interests are qualified to deliver.


Our powerful computers seem unable to calculate the value of what really matters


The motto of the Royal College of General Practitioners is “Cum scientia caritas”—scientific knowledge applied with compassion. It is a worthy motto that I am happy to support. It promotes the idea that I should strive to maintain a rigorous scientific approach, to provide effective care with a sound evidence base. It assumes, of course, that it is possible to rigorously define a sound evidence base for the science I apply. However, the science is only half the story. The motto also proclaims the importance of compassion, and with it the value of the art of medicine. In applying modern medical science, with a wide range of potentially life saving investigations and treatments at my disposal, I can now treat many patients who would have been denied effective intervention in the past. However, I help repair many other lives blighted by anxiety, depression, grief, and despair not through recourse to science but through the art of medicine.

I recently saw a patient, weakened by the festering emotions of a delayed grief reaction, approaching the first anniversary of her loss. I used the tools at my disposal as best I could: my time, empathy, and trust, active listening, reflection, response to cues, challenge, encouragement, and the sharing of some knowledge we doctors hold about the nature of grief reactions. In time the emotions began to be released, the deepest fears were expressed and expelled, the patient began to improve, and my efforts were rewarded. But where is my evidence? In any number of similar therapeutic consultations how do I calculate the P value of empathy or the statistical significance of trust or active listening? How do I claim payment for my efforts? I can record a minor surgical “incision and drainage” operation on a spreadsheet, confirming the procedure, the skill involved, and the resulting fee required. But how do I account for this consultation? The skill of a community doctor, providing “incision and drainage” for this patient, was as important for her wellbeing as any minor operation. Then how do I display my evidence? After all, the purpose of my consultation with this patient was not to impose a scar on a visible part but to remove a scar from an invisible part.

The nature of the human condition has not changed over the millennia. We remain vulnerable to our weaknesses, no matter what scientific knowledge prevails. The evidence I have for the value of the art of medicine lies in the timeless nature of the human condition to seek aid when in need and to receive that aid from someone who is skilled and dedicated to helping their fellow humans. Increasing population mobility, rising numbers of family break ups, and the declining role of religion leave many traditional sources of aid beyond reach, though the community doctor remains readily accessible, within 48 hours.

In this age of science and technology and rapid access to limitless information, our powerful computers seem unable to calculate the value of what really matters. In defending the role, status, income, and future of community doctors, science and statistics will no doubt play their part. However, because they form only part of our work they should also form only part of the debate. I believe it is time for our profession to assert the value of the art of medicine.