Kindness and compassion: part of professionalism

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 this patient’s 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 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.

Showing we care

Was this behaviour ‘unprofessional’? Or is there room for fam- ilies, 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 over-familiarity, 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 that 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 where 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 behaviour’ after the resident he was supervising at the clinic shared this incident with the clinic director.¹

Of course, there are some professional boundaries that we must always respect. Boundaries that prevent us from offering unrealistic expectations, from acting in ways that 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 humanly 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.

Compassion and patient safety

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 in the Mid Staffordshire Trust hospitals there was ‘an apparent lack of compassion among healthcare workers’.²

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.³ Powerful recommendations: listen to patients; model transparency; model trust; keep on learning.

How to teach ‘healing’

How should concepts like kindness and compassion be taught to medical students as part of their professionalism teaching? Can they be taught? Focus groups with students from three medical schools in New South Wales found that although the students regarded professionalism as important, they had a low opinion of the way it was taught at their universities. They thought that professionalism would be best taught in a clinical context, or in a seminar, where they could look at problems with ethical or legal issues.⁴ One of their criticisms was the discrepancy between what was taught and the conduct of some of their teachers and other members of the profession, a discrepancy that seemed to be widely tolerated.^5-7

Last September, an article in The New York Times began by pointing out that healing involves far more than knowledge and skill.⁸ It went on to say that the other necessary qualities involved in healing (including altruism, empathy and compassion) are not often taught and often not role-modelled for students. In contrast, it pointed out that there is another curriculum, a hidden one, a curriculum that is not taught formally but which can be experi- enced in senior medical student and junior doctor years. This is the curriculum that says ‘don’t ask for help, it’s a sign of weakness’, ‘If you make a mistake, don’t admit it, try to cover it up’, ‘Stay detached’, ‘Stay objective’, ‘Have a little cynicism’.

The real aim of The New York Times article was to describe a counterbalance to some of these obstacles, an innovative, voluntary course, ‘The Healers Art’, which started in 1992 at the UCSF School of Medicine. It is now taught in 71 medical schools in the USA and in seven other countries.

The course is based on the idea that medicine draws strength from its longstanding core values: compassion, service, reverence for life and harmlessness. Dr Rachel Remen, the initiator of the course, believes that connecting students and doctors to these core values helps to immunise them against the assaults of some of the things they experience and some of the behaviours they see.

It is the way the course is taught that is unusual. Students and faculty members meet together in small groups, participating side by side as equals. In this form of learning there are no hierarchies, no wrong answers and no experts. People just talk about their experiences. Or they just listen. Sometimes they use crayon to draw pictures of the parts of themselves they have difficulty bringing into their work, things such as ‘kindness’, ‘creativity’, ‘love’. In a session on grief and loss they are asked to think of a time when they experienced a loss, the feelings they experienced at that time, how the reactions of some people to their loss had been helpful while those of others had been unhelpful. They discuss how these experiences can be incorporated into the way they care for their patients.

Remen, who is clinical professor of family and community medicine at the UCSF School of Medicine, and director of the Institute for the Study of Health and Wellness at Commonweal, San Francisco, California, believes the course creates better listeners, clinicians who don’t just hear the symptoms, but also hear the patient’s story, including their hopes and fears: ‘If patients see that you care, they can trust you enough to tell you the truth and are more likely to follow your advice’.

Expertise, trust, compassion

Perhaps there is room for a program where experiences and feelings are shared in Australian medical schools, or in groups of College trainees, or with junior hospital staff. Voluntary programs where consultants, juniors and students share their feelings, learn from each other, and grow.

Because it is not only our specialised knowledge that makes us good health professionals. It is our attitudes and our behaviours that our patients will remember.

If we need to go to a doctor as a patient, we primarily want to see someone who is highly skilled. Most of us also want someone we can trust, who cares, who is compassionate and who puts our interests first.

Our patients need those same things: expertise, someone they can trust, someone who puts their interests first and who shows compassion and understanding. MT

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