Compassion and Compassion and the Education of the Education of

DoctorsDoctorsJenny Firth-CozensJenny Firth-Cozens

Imperial College LondonImperial College London

What is compassion?What is compassion? Compassion includes “empathy, respect, a Compassion includes “empathy, respect, a

recognition of the uniqueness of another recognition of the uniqueness of another individual, and the willingness to enter into individual, and the willingness to enter into a relationship in which not only the a relationship in which not only the knowledge but the intuitions, strengths, knowledge but the intuitions, strengths, and emotions of both the patient and the and emotions of both the patient and the physician can be fully engaged” physician can be fully engaged” (Lowenstein, 2008). (Lowenstein, 2008).

““A deep awareness of the suffering of A deep awareness of the suffering of another coupled with the wish to relieve it” another coupled with the wish to relieve it” (Chochinov, 2007).(Chochinov, 2007).

Students need to know that Students need to know that compassion involves:compassion involves:

• Generosity and kindnessGenerosity and kindness• Valuing othernessValuing otherness• Awareness and recognitionAwareness and recognition• HonestyHonesty• DialogueDialogue

Dialogue involves:Dialogue involves:

• Talking (not reacting) to the real Talking (not reacting) to the real person, not a stereotype person, not a stereotype

• Talking human-human, not Talking human-human, not clinician-patientclinician-patient

• Language of participation, not of Language of participation, not of professional distanceprofessional distance

• People’s lives depend on how People’s lives depend on how they are representedthey are represented

Valuing otherness Valuing otherness involves:involves:

• Enjoying differenceEnjoying difference• Difference lets you keep the boundaryDifference lets you keep the boundary• Difference helps dialogueDifference helps dialogue

• Identifying with their pain and distress, Identifying with their pain and distress, not thinking yours is identicalnot thinking yours is identical• Human relations can be:Human relations can be:

Medical-patient as objectMedical-patient as object A surfeit of empathyA surfeit of empathy

(Both are monologues)(Both are monologues) ““Alterity” – recognising that there are Alterity” – recognising that there are

differencesdifferences

What stops compassion?What stops compassion?

1. 1. An innate fear of death, disease, An innate fear of death, disease, disfigurement, distress, derangement, etcdisfigurement, distress, derangement, etc

• Physical and psychic pain in others causes Physical and psychic pain in others causes pain to those presentpain to those present

• Inappropriate humour:Inappropriate humour: …’The nurse said: “Could …’The nurse said: “Could you get this young man to go down for a chest film?” you get this young man to go down for a chest film?” I’m 55 and have terminal cancer. My guess is that she I’m 55 and have terminal cancer. My guess is that she was about 22. Please, can we avoid crass attempts at was about 22. Please, can we avoid crass attempts at humour? There’s nothing funny about clutching your humour? There’s nothing funny about clutching your clothes while trying to get a gown around you…’clothes while trying to get a gown around you…’

• Avoidance as a coping strategy: never a good Avoidance as a coping strategy: never a good one!one!

What stops compassion?What stops compassion?

2. The high stress, depression, 2. The high stress, depression, burnout and anxiety levels of burnout and anxiety levels of healthcare staff: healthcare staff:

around 25-30% on GHQ12 for around 25-30% on GHQ12 for doctorsdoctors

Organisational systems Organisational systems affecting stress and affecting stress and

compassioncompassion Menzies-Lyth’s workMenzies-Lyth’s work Industrial modelIndustrial model TargetsTargets No surplus bed numbersNo surplus bed numbers

Patients are more ill but stay less time, move Patients are more ill but stay less time, move oftenoften

Bed occupancy and antidepressant use Bed occupancy and antidepressant use (Virtanen et al.)(Virtanen et al.)

Specialisation Specialisation TeamworkTeamwork

What stops compassion?What stops compassion?

1. An innate fear of death, disease, 1. An innate fear of death, disease, disfigurement, distressdisfigurement, distress

2. The high stress, depression, burnout 2. The high stress, depression, burnout and anxiety levels of healthcare and anxiety levels of healthcare staff:staff: around 25-30% on GHQ12 for around 25-30% on GHQ12 for doctorsdoctors

3. The biomedical model of training 3. The biomedical model of training doctorsdoctors

What stops compassion?What stops compassion?

3. The biomedical model of training3. The biomedical model of training

• Empathy reduces over trainingEmpathy reduces over training Most medical students enter training wanting Most medical students enter training wanting

to make things betterto make things better

• Teaching it? “Teaching it? “It’s seen as soft and fluffy. It’s seen as soft and fluffy. People ask ‘Is it on the exam?’ and of course it People ask ‘Is it on the exam?’ and of course it isn’t so it’s hard to see it as important. Where it isn’t so it’s hard to see it as important. Where it is judged, it’s like a tick-box exercise – a mark is judged, it’s like a tick-box exercise – a mark for shaking hands, for saying your name…”for shaking hands, for saying your name…”

What stops compassion?What stops compassion?

3. The biomedical model of 3. The biomedical model of trainingtraining

• The scientific objectification of The scientific objectification of patients/problems:patients/problems:

Helps stop over-identifying Helps stop over-identifying with patients, but….with patients, but….

• Role models aren’t all good!Role models aren’t all good!

We were looking after an elderly female patient We were looking after an elderly female patient who was due to go home. We were all intimidated who was due to go home. We were all intimidated by the consultant – academia came before by the consultant – academia came before compassion or care with him. I had presented the compassion or care with him. I had presented the patient to him, along with our plan. He patient to him, along with our plan. He approached her and, without introducing himself, approached her and, without introducing himself, taking much history or examining her, he told her taking much history or examining her, he told her that she would not go home and needed further that she would not go home and needed further tests. He walked away at this, instructing me as tests. He walked away at this, instructing me as he went on the tests to be arranged, and leaving he went on the tests to be arranged, and leaving the patient in tears. I had to follow him to listen the patient in tears. I had to follow him to listen to my instruction and so was unable to stay and to my instruction and so was unable to stay and explain things to her. At no time could I do as I explain things to her. At no time could I do as I would have chosen.would have chosen.

Enabling compassionEnabling compassion1. Training1. Training::

the human aspects of medicine must be the human aspects of medicine must be valued both in training and career valued both in training and career progression.progression.

• Enable proper assessment/reward for Enable proper assessment/reward for compassionate carecompassionate care

• Include compassionate care as part of PDPInclude compassionate care as part of PDP• The professions must play a part in thisThe professions must play a part in this

2. Role models2. Role models• modelling self-compassionmodelling self-compassion

• rewarding compassionate care throughout rewarding compassionate care throughout careercareer

Enabling compassionEnabling compassion

3.3. Getting close to patient/being Getting close to patient/being the patientthe patient

• Patient stories throughout training, Patient stories throughout training, preferably from the patientpreferably from the patient

• Role playing patientsRole playing patients

• ‘‘Family liaison’Family liaison’

• Doctors who are patientsDoctors who are patients

Enabling compassion Enabling compassion throughout trainingthroughout training

4. Group work: 4. Group work:

Allowing doctors to express their Allowing doctors to express their feelings and difficulties about feelings and difficulties about situationssituations

• Balint-type groupsBalint-type groups• Schwartz Centre Rounds.Schwartz Centre Rounds.

Enabling compassionEnabling compassion

5. The Organisation of 5. The Organisation of Hospital CareHospital Care Compassion takes timeCompassion takes time A&E targets – managers need A&E targets – managers need

compassion toocompassion too Staffing / bed occupancyStaffing / bed occupancy Rewarding compassionate careRewarding compassionate care Board executive and non-executive Board executive and non-executive

for ‘humanity in healthcare’for ‘humanity in healthcare’

… … and in case someone you and in case someone you talk to still wonder why it talk to still wonder why it matters…matters…

Why patients need Why patients need compassioncompassion

• Increases patient satisfaction: Patients Increases patient satisfaction: Patients report compassion is missing from their carereport compassion is missing from their care

• Compassion affects outcomes: reduces Compassion affects outcomes: reduces stress hormones which affect wound stress hormones which affect wound healing; healing;

• Clinicians with a good bedside manner:Clinicians with a good bedside manner:- Obtain better information about patients’ - Obtain better information about patients’

symptoms and concerns, andsymptoms and concerns, and

- Create treatment plans that improve patient - Create treatment plans that improve patient recoveryrecovery

Why organisations need Why organisations need to give compassionto give compassion

Patients are less likely to sue if they Patients are less likely to sue if they receive compassionate carereceive compassionate care

Nurses leave the profession when their Nurses leave the profession when their values conflict with realityvalues conflict with reality

Patients in A&E re-attend less with Patients in A&E re-attend less with compassionate carecompassionate care

Good for staff: giving compassion is a Good for staff: giving compassion is a natural adaptive activity and being natural adaptive activity and being good is good for yougood is good for you