1. Compassion and the Education of Doctors Jenny Firth-Cozens Imperial College London

2. What is compassion? Compassion includes empathy, respect, a recognition of the uniqueness of another individual, and the willingness to enter into a relationship in which not only the knowledge but the intuitions, strengths, and emotions of both the patient and the physician can be fully engaged (Lowenstein, 2008). Compassion includes empathy, respect, a recognition of the uniqueness of another individual, and the willingness to enter into a relationship in which not only the knowledge but the intuitions, strengths, and emotions of both the patient and the physician can be fully engaged (Lowenstein, 2008). A deep awareness of the suffering of another coupled with the wish to relieve it (Chochinov, 2007). A deep awareness of the suffering of another coupled with the wish to relieve it (Chochinov, 2007).

3. Students need to know that compassion involves: Generosity and kindness Generosity and kindness Valuing otherness Valuing otherness Awareness and recognition Awareness and recognition Honesty Honesty Dialogue Dialogue

4. Dialogue involves: Talking (not reacting) to the real person, not a stereotype Talking (not reacting) to the real person, not a stereotype Talking human-human, not clinician- patient Talking human-human, not clinician- patient Language of participation, not of professional distance Language of participation, not of professional distance Peoples lives depend on how they are represented Peoples lives depend on how they are represented

5. Valuing otherness involves: Enjoying difference Enjoying difference Difference lets you keep the boundaryDifference lets you keep the boundary Difference helps dialogueDifference helps dialogue Identifying with their pain and distress, not thinking yours is identical Identifying with their pain and distress, not thinking yours is identical Human relations can be:Human relations can be: ­ Medical-patient as object ­ A surfeit of empathy (Both are monologues) ­ Alterity – recognising that there are differences

6. What stops compassion? 1. An innate fear of death, disease, disfigurement, distress, derangement, etc Physical and psychic pain in others causes pain to those present Physical and psychic pain in others causes pain to those present Inappropriate humour: …The nurse said: Could you get this young man to go down for a chest film? Im 55 and have terminal cancer. My guess is that she was about 22. Please, can we avoid crass attempts at humour? Theres nothing funny about clutching your clothes while trying to get a gown around you… Inappropriate humour: …The nurse said: Could you get this young man to go down for a chest film? Im 55 and have terminal cancer. My guess is that she was about 22. Please, can we avoid crass attempts at humour? Theres nothing funny about clutching your clothes while trying to get a gown around you… Avoidance as a coping strategy: never a good one! Avoidance as a coping strategy: never a good one!

7. What stops compassion? 2. The high stress, depression, burnout and anxiety levels of healthcare staff: around 25-30% on GHQ12 for doctors

9. Organisational systems affecting stress and compassion Menzies-Lyths work Menzies-Lyths work Industrial model Industrial model Targets Targets No surplus bed numbers No surplus bed numbers Patients are more ill but stay less time, move often Patients are more ill but stay less time, move often Bed occupancy and antidepressant use (Virtanen et al.) Bed occupancy and antidepressant use (Virtanen et al.) Specialisation Specialisation Teamwork Teamwork

10. What stops compassion? 1. An innate fear of death, disease, disfigurement, distress 2. The high stress, depression, burnout and anxiety levels of healthcare staff: around 25- 30% on GHQ12 for doctors 3. The biomedical model of training doctors

11. What stops compassion? 3. The biomedical model of training Empathy reduces over training Empathy reduces over training Most medical students enter training wanting to make things better Most medical students enter training wanting to make things better Teaching it? Its seen as soft and fluffy. People ask Is it on the exam? and of course it isnt so its hard to see it as important. Where it is judged, its like a tick-box exercise – a mark for shaking hands, for saying your name… Teaching it? Its seen as soft and fluffy. People ask Is it on the exam? and of course it isnt so its hard to see it as important. Where it is judged, its like a tick-box exercise – a mark for shaking hands, for saying your name…

12. What stops compassion? 3. The biomedical model of training The scientific objectification of patients/problems: The scientific objectification of patients/problems: Helps stop over-identifying with patients, but…. Helps stop over-identifying with patients, but…. Role models arent all good! Role models arent all good!

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

14. Enabling compassion 1. Training: the human aspects of medicine must be valued both in training and career progression. Enable proper assessment/reward for compassionate care Enable proper assessment/reward for compassionate care Include compassionate care as part of PDP Include compassionate care as part of PDP The professions must play a part in this The professions must play a part in this 2. Role models modelling self-compassion modelling self-compassion rewarding compassionate care throughout career rewarding compassionate care throughout career

15. Enabling compassion 3. Getting close to patient/being the patient Patient stories throughout training, preferably from the patient Patient stories throughout training, preferably from the patient Role playing patients Role playing patients Family liaison Family liaison Doctors who are patients Doctors who are patients

16. Enabling compassion throughout training 4. Group work: Allowing doctors to express their feelings and difficulties about situations Balint-type groups Balint-type groups Schwartz Centre Rounds. Schwartz Centre Rounds.

17. Enabling compassion 5. The Organisation of Hospital Care Compassion takes time Compassion takes time A&E targets – managers need compassion too A&E targets – managers need compassion too Staffing / bed occupancy Staffing / bed occupancy Rewarding compassionate care Rewarding compassionate care Board executive and non-executive for humanity in healthcare Board executive and non-executive for humanity in healthcare

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

19. Why patients need compassion Increases patient satisfaction: Patients report compassion is missing from their care Increases patient satisfaction: Patients report compassion is missing from their care Compassion affects outcomes: reduces stress hormones which affect wound healing; Compassion affects outcomes: reduces stress hormones which affect wound healing; Clinicians with a good bedside manner: Clinicians with a good bedside manner: - Obtain better information about patients symptoms and concerns, and - Create treatment plans that improve patient recovery

20. Why organisations need to give compassion Patients are less likely to sue if they receive compassionate care Patients are less likely to sue if they receive compassionate care Nurses leave the profession when their values conflict with reality Nurses leave the profession when their values conflict with reality Patients in A&E re-attend less with compassionate care Patients in A&E re-attend less with compassionate care Good for staff: giving compassion is a natural adaptive activity and being good is good for you Good for staff: giving compassion is a natural adaptive activity and being good is good for you