The process of empathy: insights from John Berger’s A Fortunate Man

INTRODUCTION

A Fortunate Man: The Story of a Country Doctor, by John Berger and illustrated by Jean Mohr’s photographs, was published almost 50 years ago but has recently been reissued.^1,2 Berger describes the work of Dr John Sassall, a rural GP in the Forest of Dean.

Studying the book provides insights into the process of empathy. There is agreement that we need more of it in medical care, although conflicting evidence suggests that medical students experience a decline in their empathy levels during training.^3–6 A Fortunate Man also warns of the dangers of going beyond empathy and becoming overwhelmed by the patients’ suffering.²

An interpretivist approach has been used to explore the text of Berger’s book through a phenomenological lens.⁷ This involves a double hermeneutic: the reader is interpreting Berger’s interpretation of Sassall’s views and experience of a 6-week period of his practice. Berger acknowledges the subjectivity of his observations and yet from a phenomenological perspective his insights resonate with the problems facing GPs today. The aim of this analysis is to identify themes relating to the process of empathy in the book and stimulate debate about empathic relationships in general practice today.

EMPATHY

Empathy is a complex, multifaceted construct that has been defined in many different ways.⁸ For some doctors empathy has been defined in narrow cognitive terms leading to a form of ‘detached concern’.⁴ This study adopts a broader approach highlighting empathy’s cognitive, affective, behavioural, and moral aspects.^9,10

CONNECTION

Berger is struck by Sassall’s connection with patients, seeing empathy as a relational process rather than a personal attribute. Sassall begins by spending time with the patient, appreciating the importance of the first contact and learning about the person before considering their illness:²

‘“The door opens,” he says, “and sometimes I feel I’m in the valley of death. It’s all right once I’m working. I try to overcome this shyness because for the patient the first contact is extremely important. If he’s put off and doesn’t feel welcome, it may take a long time to win his confidence back and perhaps never. I try to give him a fully open greeting. All diffidence in my position is a fault. A form of negligence.”’ ²

The doctor’s relationship with his patient is intimate at both a psychological and a physical level. The promise of intimacy without sexual overtones encourages trust and allows patients to submit their bodies to physical examination and to confide their deepest fears.²

CURIOSITY

The word ‘curiosity’ hardly does justice to the empathic concern and commitment that Sassall shows his patients.² Sassall attempts to see the world through the patient’s eyes using his imagination and curiosity while at the same time maintaining a self–other boundary.

Empathic concern inevitably results in a sharing of emotion and Sassall feels the pain of his patient.¹¹ Berger observes him weeping as he leaves a dying patient’s home yet he seems enhanced rather than diminished by his tears.² This appropriate empathic concern should be distinguished from personal distress resulting from a self-oriented perspective (‘How would I feel in this situation?’), which can overwhelm the doctor.

PRESENCE

Sassall spent more time visiting patients in the Forest of Dean than sitting in his surgery.² A home visit deepens a relationship and engenders trust. Sassall shows that empathy can be enhanced by simply being present; his arrival at a scene of crisis has a calming effect. Aware of the importance of human contact with his patients, he recounts talking to a husband immediately after the death of his wife:

‘“It sounds a funny mixture,” said the old man without looking up, “heart trouble and then pneumonia. A funny mixture. She was quite well yesterday.” He began to cry, very quietly, like a woman can; the tears welling up in his eyes. The doctor, who had already picked up one of his bags, put it down again and leant back in the chair. “Can you make us a cup of tea?” he said. While the daughter was making the tea the two men spoke about the orchard at the back and this year’s apples.’²

CONTINUITY

Continuity deepens empathy and is another strong theme in Sassall’s work.² Nowadays most patients cannot identify with ‘their’ GP because they belong to a practice team.¹² Sassall in his thirst for experience and knowledge is undoubtedly overworked, but knowing the context of the patient and their illness is a vital part of his sometimes unconventional approach.

HUMANITY

Sassall’s humanity creates a sense of security in situations of great uncertainty. He has a sense of humour that his patients are happy to share. Sassall likes to think that anybody can say anything to him:

‘“What have you got on?’” he asks a waitress about a menu in a factory canteen. “Do you want to start at the top” answers the girl at the counter pointing to her breasts, “or at the bottom?” lifting her skirts up high. Yet she knows she is safe with the doctor.’ ²

DEPRESSION

The gap between Sassall’s privilege and sensitivity and his patients’ underprivileged lives causes him to despair.² His depression is also triggered by feelings of inadequacy in the face of the suffering of the patients. Sassall’s depression is tragic in the light of his suicide 15 years after the book was published.

Empathy requires effort and so often is emotionally draining.¹³ If appropriate empathic concern slides into identification and personal distress then the doctor is at risk of being overwhelmed by emotions and becoming depressed.¹¹

THE PROCESS OF EMPATHY

The ‘empathy cycle’ is a process where both patient and doctor learn more of each other over time in an iterative deepening of their relationship.¹⁴ Empathy involves recognition of the patient as a fellow human being and developing a sense of fraternity.² Imagination, or perspective taking, is integral to this process. Sassall seeks the underlying hidden agenda each patient brings, listening to their story and allowing time to pass. In the process of empathising he is focused on the patient and Berger describes him as almost losing his identity in that of the patient.² Sassall has the patients’ trust as an advocate for them, not as a priest representing a higher power.² To maintain this delicate psychological balance between detachment and connection, Sassall reflects on his work, sensing that his feelings about a patient are a valuable source of information. His humility means that he is indifferent to success or academic recognition. His commitment to his patients is clear: he lives among them, he is one of them.²

Empathising is a creative process that changes and develops with experience. Sassall started his medical career being a practical doctor interested in curing people. In his thirties, influenced by reading Freud, he wanted to learn more about the person before their illness. As his empathy developed his practice became more patient-centred.²

It was not just Sassall who changed; the continuity he had with his patients meant that they grew up with him, leading to a deeper empathetic relationship.

NOSTALGIC PROFESSIONALISM

Sassall puts his patients and his work before his personal life, viewing the patient as almost sacred.² This form of professionalism is sometimes referred to as nostalgic professionalism.¹⁵ Sassall demonstrated a way of practising medicine that has almost completely disappeared, yet, in his fulfilled existence, work and life became one.

Sassall presents himself to his patients as an equal, prepared to share his vulnerability. In some sense this self-disclosure is an essential part of the reciprocity of empathy. Sassall describes himself as:

‘A man who was all-knowing but looking haggard. Once a doctor came in the middle of the night and I could see that he slept too — his pyjama trousers were poking out through the bottom of his trousers. But above all I remember he was in command and composed — whereas everybody else was fussing and agitated.’ ²

CONCLUSIONS

If doctors are to establish close therapeutic relationships with patients they need to be given time to establish empathy, to acknowledge the individuality of the patient and to properly address their concerns. It has even been suggested that GPs might be rewarded on the basis of the length of their consultations.¹⁶ Time, presence, curiosity, and imagination combine in empathy to recognise the person, not simply their illness.

Doctors and medical students need support with emotional regulation and in enhancing their empathetic skills. This may involve addressing some of the barriers blocking their innate empathy.^3,17 Doctors need to develop the self-awareness to recognise the difference between empathic concern, which is an essential part of professionalism, and personal distress, which can be self-destructive.

However, it is not good enough to provide doctors with training or exhortations to be more empathic and then expect them to work in an environment that does not support empathy. Support needs to be available for all doctors and medical students, not just reserved for those perceived to be struggling.¹⁸ A reflection on Sassall’s practice can rekindle a conversation as to how to enhance empathy in general practice too.