"We do not believe in ourselves until
someone reveals that something deep inside us is valuable, worth listening to,
worthy of our trust, sacred to our touch."
e.e. cummings
To be optimally beneficial for patients, every physician without exception should be both technically excellent and practice with compassionate care. However much the technical advances in medicine are beneficial to patients, no one who is ill should have to suffer the indignity of a technically competent but uncaring doctor, nurse, or other staff member. Good medical practice has been perennially captured in the phrase "the art of medicine," which combines both scientific-technical knowledge with humanism, defined as the physician's interest in and respect for the patient as a person experiencing illness. Too many patients experience de-humanizing and impersonal treatment, so much so that this is now a crisis in healthcare systems, proving destructive not only for patients, but for professionals, families, and the systems themselves.
That compassion should be an essential quality in optimal medical care constitutes universal and perennial wisdom in medical ethics. The oft-quoted Dr. Francis Peabody of Harvard wrote nearly a century ago, "The secret to the care of the patient is in caring for the patient." In the absence of compassion, patients are dissatisfied and professionals lament a loss of meaning and gratification in their work. Healthcare systems that gain reputations for inhumane care are unable to compete and lose revenue. For the most part, the solution lies in the small acts that show care. Good is in the details, and we must all accept that we are role models.
The care of the patient is both a science and an art. It is on the one hand the competent application of science; on the other hand it is the art of being attentively present to the patient in a manner that facilitates well-being, security, treatment adherence, and healing. Compassionate care is the essence of this art. What does "compassion" add to "care"? It adds an element of stronger affective response and deeper awareness of the concrete reality of the patient's "illness" experience. Depersonalization and dehumanization often leave patients feeling like "the kidney in room five." Nevertheless, a truly "healing relationship" that manifests emotional and social intelligence in response to illness will always remain central to good clinical outcomes. By "illness" we mean the subjective experience of disease as it interweaves with meaning systems, social networks, hopes, emotions, and values. Every patient has a story or "illness narrative" that needs to be respected; no patient is a mere biological puzzle to be "figured out." It's the loss of care in its most basic sense that is currently being singled out across the United States as a pressing ethical concern not only of patients, but of physicians and other healthcare professionals.
Bernard Lown, MD, one of the greatest cardiologists of our time, the inventor of the defibrillator, and recipient of the Nobel Peace Prize for founding and developing International Physicians for the Prevention of Nuclear War, wrote a classic book is entitled The Lost Arts of Healing: Practicing Compassion in Medicine (1996). It is a powerful statement about how compassionate care, often in the form of attentive listening, creates a "healing relationship"with patients that improves diagnostic clarity, patient outcomes, patient adherence with treatment, and brings immense gratification to the professional as well. As a cardiologist, of course, Lown is constantly aware of how closely protracted negative emotional states are associated with stress and heart disease. Thus, he views the physician-patient relationship as being as important as any technical medical intervention, and sometimes more so. His underscores how many times his diagnoses based on careful listening in a caring mode were more accurate than those of colleagues who centered their assessment on various tests but did not connect, affirm, and listen to patients. As Lown describes, it is impossible to treat a patient optimally without the basic "care" that allows for positive emotions to displace anxiety or hostility, which in turn influence healing processes within limits as is now scientifically understood at the levels of neurology, immunology, and endocrinology. Thus, it behooves us to reflect on why treating patients with compassion matters based on the best contemporary science.
In all healthcare systems, we ought to aim for a culture of compassionate care in which patients will not experience humiliating insensitivities or rudeness, but rather compassion, respect, reassuring manner (appropriate etiquette, dress, speech) hospitality & attentive listening; interactions with patients are uniformly recognized as having the significance of any important clinical intervention; physicians, nurses and all staff will find patient care more gratifying and meaningful; benevolent and respectful interactions between members of the healthcare team will be understood as establishing the secure base from which the compassionate care of patients unfolds; and the clinical learning environment inspires students with a pervasive ethos of compassionate respect, and eliminates their complaints of patient and/or student maltreatment.
Four Beneficiaries of Compassionate Care
There are four potential beneficiaries of compassionate care in the healthcare setting:
FIRST, clinicians, nurses, residents and other staff benefit. Jerome Groopman, MD, a great Harvard University doctor and author, wrote, "The entire compassionate dimension of medicine, which is really key to the profession and which is so gratifying - all of that is threatened, severely threatened, if not erased, when you are put in an environment where you are constantly hectored around money and efficiency and making sure that time is minimized with patients in delivering care, in order maximize revenue" (Groopman, 2009). The compassionate care, then, that is so uplifting and meaningful for the doctor is denied them unless they truly make the effort, which indeed they can, to practice medical compassion rather than medical disrespect. We know some hard facts about how the stifling of compassion harms physician morale:
87% of physicians who report erosion in enthusiasm for medicine (58% of 2,608 surveyed nationally in the US) attribute this loss to the inhibition of empathic care (Zuger, 2004).
Clinicians' satisfaction with their relationships with patients can protect against professional stress, burnout, substance abuse, and even suicide attempts (Shanafelt, 2009)
Up to 60% of primary care clinicians report symptoms of burnout, defined as emotional exhaustion, depersonalization (treating patients as objects), and low sense of accomplishment. This is linked strongly associated with poorer quality of care, patient dissatisfaction, increased medical errors, lawsuits, and decreased expressions of empathy. Substance abuse, stress-related health problems, marital and family discord, and automobile accidents are among the documented consequences for physicians. Participation in a "mindful communication program" (didactic material, formal mindfulness meditation, discussion) consisting of 8 weekly 2.5 hour sessions, plus one all-day session,was associated with short-term and sustained improved in well-being and attitudes associated with patient care (Krasner, et al., 2009).
It is not the case that most professionals do not want to care about patients, but they become very task oriented in an environment where speed is praised and rewarded, and as a consequence they can lose sight of the patient as a person unless they are both self-aware and intentionally care-full. If they lose the deeper meaning of their professional lives, many will eventually suffer adverse consequences. It takes considerable resolve to carve out the space for compassionate care regardless of environment, but in the end, doing so involves relatively small purposeful acts that change the emotional and social quality of an interactions so as to allow greater salugenesis.
There is a certain humility involved is carving out this space. Humility requires unflinching self-awareness, empathic skills, and gratitude for the privilege of caring for sick persons (Coulehan, 2010).
Small acts take many forms. A simple question or comment does wonders, e.g., "This must be pretty tough on you yes?" "How are you handling this and do you need some help?" "It's natural to feel pretty overwhelmed at time like this." We hope to have a cultural affirmation at our medical center as follows: Whenever I interact with any person at Stony Brook University Medical Center, without exception, I treat them with respect, compassion, hospitality and good manners. Small Acts Show I Care.
