Tim Norfolk: Medical knowledge is nothing without empathy

When you hear someone say, "I've got a good GP", what do they mean? Certainly that the GP is a competent doctor but also, usually, that he or she is friendly and understands their needs. What's interesting is that we tend to separate the two qualities – the clinical skills being seen as essential and the interpersonal skills as a bonus. Our present experimental research, involving 187 doctors in the Trent Region, suggests this may be a false distinction.

The research suggests not only that interpersonal skills such as empathic understanding may play a significant role in developing an accurate clinical diagnosis but, interestingly, that specific aspects of personality – especially enthusiasm and a flexible outlook – may also contribute to best practice as a GP.

To understand how a doctor's personality and non-clinical skills might help, consider the unique pressure GPs face during a consultation. Someone steps into the room and tells you they have a problem, then expects you (in 10 minutes or less) to make sense of it and come up with a solution. And however apparently simple the diagnosis, you have been trained to follow a lightning sequence of "brain checks", just in case: "Define the nature and history of the problem(s), the cause(s), the patient's thoughts and concerns... then consider other continuing problems and at-risk factors, reach a shared understanding of the problem(s) with the patient and choose an appropriate action for each..."

All in 10 minutes. Some challenge, that. This complex process may be repeated about 30 times a day: 30 patients, 30 stories, 30 acts of rapid decision-making. Many will be straightforward, but a random few will be more complicated than they initially seem.

It may be a single comment or movement of the body that stands out from an otherwise familiar set of signals from the patient. The clue, perhaps, to an underlying problem. To miss that single clue, the "marker gene" in the jigsaw, might lead to a misdiagnosis, inappropriate treatment and increased risk to the health of the patient. And international statistics suggest about 50 per cent of patient concerns are not picked up during GP consultations. In summary: a difficult job with potentially high risks attached.

The two interpersonal skills which seem to play a more significant role are communication skills (being an active listener, asking open questions, maintaining eye contact) and empathic understanding (recognising and respecting the feelings that lie behind the story that unravels in the surgery).

A patient sitting opposite a GP he feels lacks such skills may be less inclined to reveal enough of his particular story, enough potentially relevant symptoms, to allow for an effective diagnosis. If so, a GP with the finest clinical knowledge may struggle.

Most recently, however, we have also found that personality may play a part. Two particular personal traits seem to be helpful. The first is a positive and active enthusiasm that allows someone to "lift the atmosphere" of a room. In the GP's case, it might generate hope or reassurance in the patient by reframing a problem to highlight the positive. The second is a natural curiosity, an enjoyment of variety or "difference", that allows someone to be comfortable with change or uncertainty.

Operating together, these characteristics and skills help generate a positive and receptive atmosphere when a patient steps into the room. In a very real sense, then, the non-clinical seems to facilitate the clinical.

Given such findings, it is perhaps surprising that undergraduate medical training, largely knowledge-based, spares comparatively little time to address the influence of personal traits or interpersonal skills on performance. We would suggest that the balance in both undergraduate and GP training, between the study of clinical and non-clinical skills, needs to be re-addressed. It is a balance that is certainly being redrawn in GP selection and training within the Trent Region.