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WAY back in my intern days, it was unusual for consultants to talk with their “public” patients, apart from a quick comment on a ward round. The hard stuff was often left to us — the interns, young people with minimal life experience, an overwhelming workload and no training in the gentle art of communication.
At my teaching hospital a time was set aside once each week when family members could come to the hospital foyer, page the intern and ask questions about their loved one’s condition.
In my third month after graduation I assisted at a laparotomy on a fit, active 54-year-old man who presented with a hard lump at his umbilicus. The laparotomy showed widespread cancer with multiple metastases. The surgeon closed the wound. There was nothing to be done.
That afternoon happened to be the one when family members could meet the intern. It was my job to tell his unsuspecting wife when she came to the foyer to ask about her husband’s operation. I told her the truth as kindly as I could. Her eyes welled up with tears. So did mine.
Afterwards, I felt embarrassed about my show of emotion. Why couldn’t I be “more professional” like my consultants? I wondered if I was really suited to do medicine. Later, I realised that it may have helped her. She may have seen that even though the news was bad, I cared.
In subsequent years, as a consultant, my eyes would sometimes moisten when I had to tell a parent that their child would not survive. And sometimes it happened when I had the pleasure of giving unexpected, but joyful news.
Was this behaviour “unprofessional”? Or is there is room for families, junior doctors and medical students to realise that we, the more senior doctors, do care? To realise that there is more to it than striding the narrow catwalk between aloofness and overfamiliarity, that there is a place to show humanity and that it is not unprofessional to let people know we care.
However, when clinicians show compassion which may extend beyond what is normally seen as “professional” they may be criticised. Dr Gordon Schiff, the associate director of the Center for Patient Safety Research and Practice at Brigham and Women's Hospital in Boston, Massachusetts, recently described an incident when one of his patients had problems negotiating the complex US insurance system to be able to pay for her medication.
Schiff decided that it would be kinder, instead of saying “I’m sorry, I can’t help you”, to reach into his pocket and hand her the $30 she needed to be able to fill the prescription he had given her. He did so. To his surprise he was reprimanded for “unprofessional boundary-crossing behavior” after the resident he was supervising at the clinic shared this incident with the clinic director.
Of course, there are some professional boundaries which we must always respect. Boundaries which prevent us from offering unrealistic expectations, from acting in ways which are of dubious legality and from confusing personal and professional relationships, particularly in the sexual realm.
However, these well accepted boundaries are different from really caring about our patients and doing something about it. Schiff argues that too strict an interpretation of professional boundaries “risks encouraging detached, arms-length, uncaring relationships” with this type of bounded thinking serving “to rationalize abdication of our professional and personal responsibilities to humanely respond to patient suffering and underlying injustices”.
We don’t have to take off our compassion, or our ability to show it, when we drape a stethoscope around our neck. The need for doctors to be professional is not synonymous with being emotionless.
There is more to this than just being nice to people. It is about being kind. It also has implications for the quality of patient care.
The 2013 Francis Report on the Mid Staffordshire NHS Foundation Trust Public Inquiry found that patients had died from avoidable causes and that many more suffered unnecessary indignities and harm. The report concluded that there was “an apparent lack of compassion among healthcare workers” at the hospitals.
An expert panel formed to respond to the inquiry findings recommended that the quality of patient care, especially patient safety, must be the aim above all others. In view of this priority, it recommended that patients and their carers should be engaged, empowered and heard everywhere and at all times in the health system and that clinicians and administrators must insist upon, and model in their own work, thorough and unequivocal transparency in the service of accountability, trust and the growth of knowledge.
Powerful recommendations — listen to patients; model transparency; model trust; keep on learning.
Professor Kim Oates is the director of undergraduate quality and safety education with the Clinical Excellence Commission.
This is an abridged version of an article published this month by the Royal Australasian College of Physicians in the RACP News magazine
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It seems that the foundation to compassion is a capacity for us to first be with our own difficult feelings such as sadness or anger, and then to be responsive guided by core values such as compassion, service and reverence for life.
Mindfulness or the purposeful and non-judgemental attentiveness to one’s experience, thought and feelings, addresses this first capacity and has recently been studied in physicians.
There are two interesting articles from last years Annals of Family Medicine: A Multivariate Study of Physicians Mindfulness and Health Care Quality and an Abbreviated Mindfulness Intervention for Job Satisfaction, Quality of Life and Compassion in Primary Care Clinicians: A Pilot Study that suggests that mindfulness can be taught. Married with some of Dr Remen’s ideas it would provide a good foundation for the teaching of compassion.
Isn’t it time for a professionn founded on compassion to have it taught as part of a curriculum?
And by the way,if you ever get a chance to read some of Rachel Remen’s books, do so because they are wonderfully inspiring and filled with wisdom and compassion.
Thank you Professor Oates for your insights. I remember a medical colleague of mine once saying that as medical students you need to develop a ‘medical gaze’ throughout your training as there is so much to learn. As you get older and practise medicine, you need to develop more the ‘human gaze’. In this way, health care becomes moves from being transactional to interactional. And it not only benefits the patient, it benefits the doctor too. In deepening the patient’s jouney of understanding and ‘growing through their illness’, the clinican deepens their own humanity. I’ve always believed that suffering deepens our awareness of humanity, if we but engage with it in all its depths.
From a Medical Support Services point of view currently – and the child of medicos – I think that the wider community needs to realise that health professionals – and their support staff, inadvertently – are constantly at risk of mental and emotional fatigue due to the phenomenal pressure of a patient’s immediate emotional response and general wellbeing at any given time.
Working in Paediatrics and private administration, I have seen how the anxiety of a parent becomes overwhelmingly difficult to deal with – to the point at which nobody wants to be helpful anymore. Trying to alleviate the stress of a carer in some cases seems to lead to more and more taxing demands on the consultant – or the administrative staff who are constantly bombarded with e-mails and phone calls. At what point do some people recognise health providers as human beings with families and friends and their own feelings?
Are health professionals taken for granted if they do not promote a stern boundary from the outset?
Compassion should be the sole reason for becoming a doctor because only a heart filled with compassion can feel for the needs of suffering humanity and only this compassion should lead to craving for medical knowledge so that we can treat our patienta with compassion and knowledge.The aim should be to heal the patient on a physical as well as mental level as sometimes a word of hope wisdom or strength can give the patient a sense of relief .The patient is not suffering on a physical level but on mental level too..But with compassion wisdom of controlling our emotions is also necessary so that we do not loose our focus and concentration because emotions can be like wild horses difficult to control.What every doctor needs to be is a wise compassionate healer.
of course kindness is vital ingredient for all health practitioner interaction.. however couple of points:
i. too much time is spent by doctor keyboarding and looking at the screen; eye contact is diminishing.
ii. how about referring to people who consult health practitioners as people, or by name.
many people consulting are not sick; perpetuating the heirarchical implication is anachronistic.
What do patients want from their doctors?
As an anaesthetist seeing patients at their most vulnerable, just before major cancer surgery, I am constantly reminded of this quote from a patient:
“Don’t hurt me. Heal me. Be kind to me” .
All my years of training to obtain the technical skills and scientific knowledge I have, are of no use whatsoever if I cannot fulfil this simple wish.
Our patients need our true love and our true care, and that cannot come unless we are first loving and caring with ourselves and with our colleagues. Medicine is in need of a big culture shift – both in attitudes towards patients, and our attitudes towards ourselves as medical professionals, who are also human beings. Medicine has become increasingly dehumanised over the last 20 years with the emphasis being on figures, numbers, diagnostic boxes, quick consultations, and a ‘professionalism’ that creates austere and distant, yet so called effective clinicians. The castle of evidence based medicine is coming down, with our reliance on clinical trials for best practice guidelines being increasingly being shown to be not as solid as we once thought and took refuge in. 50% of clinical trials in the NEJM have been shown to be overturned within 10 years, with 15% being shown to be ultimately harmful and not effective as first shown. This brings us to greater humility as a profession and as people in the profession, and takes us to the realisation that it is about people first, and connecting with people on a human level, not as patient, not as doctor, but as person to person. This is the culture that we need to bring to medicine making it about people first.
”The answer is that she should expect – demand!- a nice, good doctor.” If only we could all be excellent technicians as well as excellent communicators – but the two don’t always go together. I sometimes wonder whether the ”technical genius” could collaborate with an excellent communicator – each working to their strengths. I’d still want the technical genius to do my surgery if I needed any.
Thank you Professor Oates for this wise article.
One of the great priveleges of my part of medicine, general practice, is to develop relationships with patients that in my case span nearly 30 years. I am seeing the children of women I delivered, and still see their grandmothers. The GP is a companion along their life’s journey. This journey inevitably involves joy and pain, and I too have shed tears of pain and joy along with my patients as together we got them through the challenges that require medical skill and compassionate support.
A colleague of mine, when once talking to a relative who bemoaned that she could not talk to her treating surgeon who was undoubtedly a technical genius, asked if she wanted a nice doctor or a good doctor! The answer is that she should expect – demand!- a nice, good doctor. Empathy is a powerful tool in our therapeutic toolkit, and one that should be used constantly.
Away, back in the dim, distant past, when I was a medical student, we were taught that the role of the physician is sometimes to cure, often to relieve but always comfort. In those days, it was thought important for a patient and doctor to establish rapport, the better to facilitate communication and thereby informed consent and cooperation. Over the past few years I have heard many complaints from patients who say “the doctor never looks at me but only at the computer and seems keen to get me out of the room as soon as possible.” Under the pretext of encouraging “objectivity” a distant coldness seems to have become the ideal for some, who, believing that the strength with which they hold their beliefs endows them with the authority to impose those beliefs on others, stare askant at any communication between others that is warmer than icy. If a medical adviser is to be more than a compliant process worker, some reasonably genuine human interaction should occur such as to facilitate diagnosis by eliciting sensitive information and to optimise “management” by engendering trust. Therefore Prof Kim Oates article to me is like a breath of fresh air!
This article provoked the following thoughts;1, that in cases where mistakes have been made, our defence organisations tell us that showing a lack of care and compassion compounds the error. If we cannot always get it right, which sadly we cannot, at least we can try always to be kind. 2 that burnout or compassion fatigue is very real and no formal support networks or medical education seem to exist to either teach us how to prevent it or to deal with it. A nurse I once worked with commented that by the end of the day “I am all niced out”. We were commiserating about the feeling that our families got the leftovers after the patients had had the best of us. Perhaps AHPRA could use some of their resources to provide support for burnt out doctors or even better for those who recognise that they are approaching burnout, it might reduce the need to reprimand and/or deregister those who make a mistake or cross a line because they finally got too worn out. 3 and sadly there is a time and money cost to caring. I could do a consult that ticked all the clinical boxes and get the patient out of my room rapidly and cheaply for them and for Medicare or I could recognise that they are worrried, stressed, on the verge of tears and take another 15-20 minutes or more with them. Who would pay? Should they ,particularly if finance is part of their stress, or will Medicare audit me and reprimand me for claiming too much without clinical justification? Then of course I run late for all my other patients thus adding to my own stress!
I think that it is important to distinguish between empathy (‘feeling for’) and sympathy (‘feeling with’) in the clinical context. Too much sympathy can result in poor judgement, professional boundary issues, and emotional ‘burn out’. Too much empathy is not enough.
Thanks for the article. There is a lot more to providing care than just medical care – physical and emotional comfort are important parts of caring for patients. Our caring need not involve pharmaceuticals or technology, sometimes reassurance, warmth, food and drink and personal interest are what someone needs to feel better. OF course, it;s easier to provide that at the mature end of one’s life than as a twenty-something.
It is a tragedy for our teaching, learning and practice within health care that we have made it normal to underrate or overlook the therapeutic value of kindness, and that it takes a jolt to realise this. Perhaps it signifies a broader social tragedy that kindness is so often overshadowed by the pursuit of individual security. It’s never too late or too early to cultivate skills in kindness and, in my experience, doesn’t seem to damage one’s sense of security. Most of us can recall clinical encounters which make for very grounded learning opportunities to hone our kindness skills, as we consider how we might manage a similar encounter better next time.
This is about being awake to our shared humanity and the compassion that flows from this. We can only ask such a question because our sytem has so marginalized the aspect of Care, Caritas, that it has lost its way. There is no ‘excellence of care’ in the absence of our shared humanity/compassion – what is left is an empty shell; it is that very caring that drives excellence of care, it has no independent existence.
From a patient point of view – Thank goodness for the end of the arrogant and aloof consultant. Being ill can be hard enough without being given the impression that you are nothing but an intellectual challenge for the clinician. IMHO, Gordon Schiff’s resident and director should have been sent for counselling! This is not just a case for kindness, it is a case for simple humanity.