Compassion in healthcare: the separation trap

The recent call for greater compassion in healthcare struck me as simplistic. Secretary of State Jeremy Hunt’s demand for more personal warmth during medical and nursing interactions came across as a bemused and impatient plea – ‘Why can’t you just…be nice!’ It was as though he could not understand why a typical doctor or nurse could be other than ever-smiling, spilling over with bonhomie, eager always to go the extra mile to make their patients’ experience of hospital as pleasant as possible. Of course, this is not the case. Why?

Healthcare professionals (HCPs) are human. They have good days and bad days. Sometimes they don’t like their jobs. And sadly, for patients, when HCPs are in a less than excellent mood the first thing to go is the soft, warm surface against which the sick are forced, by ill fortune, to rub. Underneath that surface lies the metallic functionality of a busy, hard pressed worker. Driven by a tight timetable, their day comprising a list of tasks that must be accomplished, the typical HCP will, at core, be efficient and  task focused. And when the shift ends and the time comes to hand over to colleagues, it is the lack of completion, not the absence of human kindness that should have been woven into those tasks, that will be missed.

Or have I got this all the wrong way round? The paragraph above is clearly written by a task-focused HCP.  I admit it – I have always preferred to finish a list of medical tasks than leave 20% hanging over to another day, or more likely, another colleague. Yes, even if that means the quality of those tasks is diluted, by which I mean the quality of the communication with which those tasks were framed.

So is this the choice that we present to our patients – efficiency vs compassion? It reminds me of the clichéd personality types depicted in medical fiction: who would you prefer, the brilliant and stitch perfect surgeon with few human skills, or her competent, but more empathetic colleague who did far less well in his exams? Is this really the choice?

No. Wrong again. The mistake that I have made here is in separating the task and the compassionate style with which it is performed.  They belong to each other, and the one cannot be carried out successfully without the other. The overall task can certainly be broken down to component parts, but if the visible, human face of it is neglected it cannot be said to have been completed properly. Perhaps that 100% completion rate that doctors like me were trained aim for, achieving it by and large, was always a delusion; perhaps our training, by emphasing completion, led us to become satisfied with sub-optimal care, because that vital element, compassion, was undermined.

The tendency to separate process and compassion was brought home to me a little while ago. The ward round led my team to the bed of a middle aged man with a progressive neurological disorder that rendered his speech incredibly slow, while preserving his cognitive function. His thoughts were as clear as they had ever been. On this occasion I was up against the clock – there was a meeting in 15 minutes time and he was my penultimate patient. As soon as I approached the bed I remembered how difficult our interaction was likely to be, and in a business like way I summarised the results of recent investigations and the management plan. He nodded and managed a few words, slowly, indicating that he understood everything. I moved away from the bed but paused as I heard him form the first syllable of another word. Of course I had no choice but to wait for him to complete the sentence. And that sentence was just part of a series of sentences which he had undoubtedly been considering all morning.

He wished to enlarge our discussion to explore options for future care in the community. For half a minute I attempted to finish his sentences for him, the phrases and idioms being instantly recognisable. Aware of how rude and patronizing this must seem I stopped, allowing him to complete each sentence while I swiftly composed my answer and, in the many spare seconds, controlled my growing agitation about the meeting to which I was committed. He continued.

I looked down at my feet. My body language indicated haste and impatience. I was still two steps away from the bed and standing at such an angle that it was clear I had been arrested mid-stride. Perhaps he was used to this, for he continued in a calm and measured way. I saw myself and saw how poorly I must be coming across. The interaction that had started on my terms now continued on his. I relaxed, approached the bed and closed my mind to other matters. The subject of the conversation was not particularly delicate or ethically complex. There was no great emotional unburdening, no breaking of bad news. He just needed to discuss something with his consultant. From my point of view the business of his medical management had been dealt with in a moment, but from his point of view there was more to do.

The clock ticked on, he imparted the information, told me his opinion…I responded, we had a conversation. And as I walked away, 10 minutes late for my meeting, I reflected that although I had been obliged to change my attitude and soften my style, if only for a short time, it had required quite a lot of effort. It had required me to mentally disengage from the business of the day and carve out a piece of time. I congratulated myself for the compassion I had shown, but then ridiculed myself for such shallow thinking. Although I felt that I had been especially ‘kind’, in fact I had done nothing more than be polite and had show respect to another person for quarter of an hour. And if I had walked away, having decided to ignore the effortful, muted syllable that was just the beginning of a long string of sentences, I would have denied him the chance to talk in depth with the person in charge of his care. So what seemed like a marvelous example of compassion to me was no more than a basic aspect of medical care to him.

This all seems well and good. If you begin an interaction with a patient you must commit to conducting it with compassion. But there is a sting in the tail. I was 25 minutes late to the meeting, one in which important matters were due to be discussed, where decisions were due to be taken that would in the end contribute to improved care for many other patients. So, bearing that in mind, should I have hurried off, with the justification that the needs of the many outweigh the needs of the few, or the one? Should the hard pressed ward nurse hurry from one patient to the next with barely a word, in order to serve the many rather than the few, within the allotted time?

The answer to this is a little easier to find when it is approached from the patient’s point of view. My patient, the ‘painfully’ slow talker who was desperate to explore important, if non-urgent personal matters, had no care for my timetable, my ‘commitments’, nor for the welfare of other patients, either present or future. He was focused on his situation and his relationship with his consultant. And that is the essence of the matter. Patients remember what happened to them, and are not cognizant of their small role in the complex, churning, leviathan structure of the hospital. Why should they be? They want medical efficiency and accuracy, but care greatly for the feel of things. Memories are coloured not by results or shortened stays in hospital, but by the tenor and the warmth of interactions with medical staff.

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4 comments

  1. I have this dilemma several times a day. With patients booked in every 10 minutes, every consultation that runs over has an impact on every subsequent appointment, so that the subsequent appointments in every surgery are seen progressively later. It is extraordinarily difficult to balance: http://abetternhs.wordpress.com/2011/07/24/what-doctors-do-2/
    See also John Launer on keeping patients waiting: http://pmj.bmj.com/content/88/1040/361

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  2. Thanks for this very honest reflection on an actual experience Phil – always the best way to learn, which I have done again. I remember thinking like you, that to say practitioners must demonstrate compassion, is way too simplistic. You have confirmed my impression at the time and now. First we need to understand what compassion is and feels like. I like the Dalai Lama’s definition ‘compassion is a feeling from deep in the heart that you cannot bear someone else’s suffering without taking steps to relieve it’……. You acted with compassion in that moment, sometimes I do, other times I doubt I do. Our system isn’t operating in a way that nurtures compassion – targets around patient throughput contradict the ethos of compassion, a key attribute of which is taking the time to care. But we must keep trying to build compassionate environments of care, small steps at a time, individual values nurturing team values and over time organisational values. This is what our patients deserve and expect. Thanks again for your excellent blog Phil.

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