American College of Physicians: Internal Medicine — Doctors for Adults ®

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Why compassion is such an important part of practice

From the December ACP Observer, copyright 2003 by the American College of Physicians.

Amid the daily demands of teaching and practice, it's sometimes easy to lose sight of our primary purpose as physicians: providing compassionate care to our patients.

We are all members of a professional society—the College—whose stated mission is to foster excellence in medical practice, and whose core values include sensitivity and empathy toward the needs of others. As internists individually dedicated to these values, we must never forget who and what we are, or whom and how we serve.

Sometimes we need to remind ourselves that being a good doctor is not simply a matter of maintaining technical competence. It is not enough to keep ourselves technically fit to solve diagnostic puzzles or meet therapeutic challenges. We must also nourish and exercise those humanistic qualities that our patients most want and need in their physician: kindness, personal warmth and compassion. While performance measures may assess our technical competence, these other qualities are not so easy to measure. But that doesn't mean they're not important.

Patients and their families recognize them as essential components of optimal care. And we ourselves know when those qualities are missing, when the heart seems to go out of what we do and our practice devolves to fending off "hassles" instead of engaging with our patients.

Sharing a 'terrifying uncertainty'

During my more than 35 years of practice, I cared for persons with serious hematologic disorders. My patients often required toxic chemotherapy. For many, the outcome of such arduous treatment was far from certain.

I frequently wondered how my patients dealt with the terrifying uncertainty that is often at the heart of illness. I wondered too whether I had done enough to ease their discomfort and help them maintain hope.

These reflections came into much sharper relief when I myself experienced a series of limited illnesses and saw things, albeit briefly, from a patient's perspective. My own illness and the insights I gained provoked me as a doctor to "suffer with" my patients more than I ever had before.

"Suffering with the patient" is author Joseph Campbell's classic definition of compassion in medicine. It is an imaginative leap into another's shoes, one that enables us to appreciate firsthand something of what it feels like and means to be that particular patient. Compassion involves deep feeling for others, becoming present with and responding to what we can understand of another person's predicament.

In one of his last plays, the Greek playwright Sophocles told the story of a wounded warrior who is abandoned on a desolate island, left there by his fellow sailors who could not tolerate his noisy suffering. When the title character Philoctetes speaks of his exile, his words say something about the plight of our patients, each occupying their own "island" of illness that cuts them off from the life and company they knew:

"...let me tell you of this island. No one comes here willingly. There is no anchorage here, nor any place to land, profit in trade, and be received." *

In the play, a young man arrives hoping to end the wounded warrior's exile. He earns Philoctetes' trust and gratitude by staying with him through an agonizing bout of pain and unconsciousness. Awakening, Philoctetes marvels that the young man has witnessed his suffering and not abandoned him:

"...blessed is a friend's protection. These things are beyond my wildest hopes, that you would pity me and care for my sorrows, that you would remain by me and endure my woes." *

Like that young man, each of us needs to visit our patient's "island" and learn something of his or her lonely exile. Out of that shared time may come greater trust and understanding.

The power to heal

Those of us who attended the 1999 Virginia ACP Chapter meeting heard a poignant testimonial to the power of a compassionate act to make a difference for a patient. In a stunning presentation, Steve Schalchlin, an accomplished pianist and entertainer afflicted with HIV/AIDS, told us how several years earlier he had reached the limit of his ability to tolerate not only his illness but also the toxic treatments for his many opportunistic infections. He gave up, and he was ready to die.

Late one night, when his will to live was at its lowest, a young nurse came into his hospital room. She sat with him, took his hand and quietly said, "You know, you're our favorite patient on this floor." That kind, compassionate act, Mr. Schalchlin told us, rekindled his spirit and sparked his will to live.

As Mr. Schalchlin's experience suggests, compassion in the patient-physician relationship can influence outcomes and change a patient's ability to confront an illness. Teresa Gilewski, MD, wrote in the Dec. 26, 2001, Journal of the American Medical Association about compassion's subtle yet forceful therapeutic power.

She pointed out that it is easy for physicians to focus on the power of medical science and technology—and forget about the potentially profound influence of compassion. Yet even momentary expressions of compassion by a physician can be deeply meaningful and potentially healing to a patient.

Dr. Gilewski wrote eloquently of a cancer survivor who recalled with special gratitude a young house officer who would take just "a few extra minutes" at the end of a busy day to sit and talk with him, sometimes about his therapy but often about nothing at all medical. Years after his grave illness and life-threatening treatment, the patient remained "touched by moments of compassion that enveloped him with a comfort from knowing that others wanted to alleviate some of his suffering."

Compassion's ability to transform

Dr. Gilewski wrote, too, of how compassion affects the doctor. Even in situations where we can make little apparent medical difference, offering a patient our compassionate presence means that we learn something of who this other person is, and of what it means to be human.

"In some of those 'extra moments' spent with patients," Dr. Gilewski wrote, "I've heard about unfulfilled dreams, fears and relationships. Sometimes I forget how much I've learned about life from these people."

By taking the time and interest to "suffer with" a patient, she continued, "the patient-physician relationship is temporarily suspended and transcends to one of human being to human being."

When I was in practice, I was gratified to hear patients and the families of deceased patients say that our relationship—and their perception that I truly cared about them—had helped them bear not only difficult treatments, but also the deeper anguish that a grave illness can bring.

That I had somehow shared in their suffering and allowed their suffering to touch me mattered to them deeply. That I had, in a fundamental even if momentary way, been with them on their island counted for much to them—and, also, to me.

Part of daily practice

We need to remind ourselves how important compassion can be in helping patients cope with illness and find healing. As Dr. Gilewski proposed, compassion can easily be made part of our daily practice: "The opportunity for compassion presents itself every day in every outpatient clinic, in every patient room and in every hospital hallway."

In addition to excellent clinical skills, listening, touching, and displaying genuine warmth and sensitivity to the needs of our patients and their families are the hallmarks of the compassionate physician. That compassion becomes the basis for developing the relationships that are the true source of satisfaction in practicing medicine.

We must make compassion a core element of our everyday clinical competency. Only by doing so will we be the physicians our patients want and need. We must also make sure that medical students and residents experience physicians who exhibit compassion in patient care. By observing compassion at work, this next generation of physicians will learn its artful practice.

And we must allow ourselves to engage on a human level with our patients, for their sake and ours. For me, the last word on compassion in patient care remains the simple closing statement of Francis Weld Peabody, MD, in his 1927 Harvard Medical School address: "One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient." May sustaining that interest remain our practice, our challenge and our goal.

* I'm referring to the translation by G. McNamee and published in 1986 by Copper Canyon Press.

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