Compassion means suffering with. It is about bearing witness to suffering. Bearing witness is not just being a bystander but entering into the world of the sufferer. Mirror neurones in human brains reflect this suffering. Medical students are encouraged to practice empathy. This is an act of spiritual connection, of compassion, that recognises our common humanity.
As a medical student in the early 1960s I was taught how to deal with suffering by observing the way in which my teachers dealt with it. We did not have formal teaching on ethics and relationships but we saw our teachers kneeling by bedsides, treating patients with gentleness and courtesy, as one human being to another. I accompanied a GP on visits, first in a poor neighbourhood where he took the prescription to the patient because, he said, “They will not go and collect it”’. Next we went to a patient recovering from a heart attack. The GP told me “He was just sitting in the hospital and I knew he would be better looking at his view of the Braid Hills. So I said I would look after him and he was sent home.”
Last month I read two articles on burnout in doctors, suggesting that many doctors in NZ and the US suffered from ‘compassion fatigue’. The NZ article suggests four key factors: fatigue, difficult patients, external distractions and clinical complexity. It was most common in younger GPs. It also suggests that turn offs for doctors are patients who are aggressive, smelly or dislikeable and compassion is lacking for such patients. The US article also suggested bullying by senior staff and not being supported were factors in compassion fatigue.
When I interviewed 22 NZ GPs for a thesis on spirituality, 16 of them said they had been burnt out. They were unable to respond compassionately to the needs of their patients, family and self. It was nearly always as a result of simultaneous personal and work problems and a lack of support. A number had also been bullied.
The advent of scientific medicine has changed expectations for doctors and patients. It has shifted the focus of medicine from caring to curing. The technological and therapeutic triumphs make students think that most things can be cured. They expect a medical world that is predictable and controllable. In fact it is nothing of the kind. An ageing population means that they are going to have to deal with many patients with chronic or terminal diseases. These are not curable but require care and compassion.
The innate compassion of many of the students is impressive. They spend five weeks working in a rest home and write an essay about their experience. These often show an extraordinary growth in understanding, from ignorance of the elderly to understanding them as treasures, even when they are demented or disabled. Students wonder at the rich and interesting lives of the ‘elderlies’ depicted in photographs on the walls of their rooms.
So how can compassion be enabled for doctors and patients?
Work conditions are important – recognising the limits each person has for work and providing mentoring and support. Having experienced working 80 hours a week as a house surgeon I do not think this is just about exhaustion. It is about having a community of work where all staff care for each other.
Dealing well with difficult staff is also important. I still relish the story of a contemporary of mine who when asked by a grumpy surgeon whether he thought he was God replied ‘No sir, just his house surgeon.’ The Royal Australasian College of Surgeons recently published a report about bullying in hospitals that found half the trainees had experienced it.
Doctors who continue to enjoy their work ensure that they have balance in their lives with body, mind, spirit and human connections all attended to. They have creative activities outside medicine that feed their spirit – painting, writing, gardening, climbing mountains, cooking and many others.
Junior doctors spend many hours working on computers to obtain and transmit clinical information about their patients. But they also need enough time to spend with patients and in reflection. I do wonder whether working shifts in medicine is as satisfying as caring for a patient from admission to discharge.
While spirituality is acknowledged as being important in health and healing, there is very little attention paid to it in medical school or hospitals. Scientific thinkers tend to reject concepts that cannot be explained by science. I believe that this may be partly responsible for the increase in burnout. If medical work connects doctors deeply to self, other, the natural world and the transcendent, it enables healing and growth. If cure is the main focus it fails to satisfy. Memorable patients for the doctors I interviewed were often those who died well under their good care. One of my memorable patients was dirty, smelly and unable to talk but he had a beautiful, toothless smile.
Anna Holmes MB ChB PhD is a Clinical Senior Lecturer in the Department of General Practice, Otago Medical School.
Time Magazine, Vol.180, No 9-10 September 7-14, 2015, p 44-50.
North and South, September 2015, p. 59-64.