By Adam Dudding
It's not exactly something you can turn on like a tap, says Auckland psychiatrist Tony Fernando, but nothing tells a patient that you care about their problems more clearly than if you actually start crying during a consultation.
It happened to Fernando the day he was talking to a psychiatric patient whose psychosis was coming back.
The patient had enough insight to know he was losing it again - that the voices in his head were returning. He was despairing. He was crying, and so was his partner.
The analytical, medical, part of Fernando's brain was concerned with diagnosis.
"I was thinking, 'He's getting sick again. That's annoying. The treatment isn't working.' "
But at the same time he felt terribly sad for his patient, and became "quite tearful".
Later, the patient told Fernando that seeing those tears had been important.
"He told me: 'I then had so much trust in the system that I didn't choose to end my life.' "
When people are in extreme distress, says Fernando, "they can feel so overwhelmed that they'll want to end it. All we can offer at that time is to say 'we are here for you and we'll go through this with you' ".
A doctor's display of compassion isn't always literally life-saving, but it's a crucial part of medical practice.
It's a core requirement in the New Zealand Medical Association's code of ethics. Its absence is frequently cited in complaints by health consumers to the Health and Disability Commission.
And its value isn't just touchy-feely, says Fernando. A recent Italian study showed patients of doctors with higher empathy (a precondition for compassion) ended up managing their diabetes better - it seems a doctor who actually cares will give advice more patiently, and a patient who likes their doctor is more likely to want to follow it.
Yet despite its obvious value, compassion in healthcare workers can all too easily go missing in action.
Consider the GP who tells a patient they have cancer as casually as a mechanic tells you the car's radiator needs replacing.
Or the registrar who's halfway through telling grieving relatives their father has died, only to be called away to another case before questions have been answered.
Or the doctor who starts to get snappy because their patient doesn't speak English.
When compassion falters and the patient starts to believe that the doctor doesn't really care, "it can destroy the relationship".
Which is why Fernando - an academic researcher as well as a clinician - is conducting research into compassion in healthcare, and the reasons it sometimes runs dry.
Collaborating with Auckland University associate professor Nathan Consedine, Fernando surveyed hundreds of doctors in New Zealand and in the Philippines (his homeland) about what they saw as the barriers to compassionate care.
The study is awaiting final review in an international journal, but in the meantime Fernando has written an article on compassion for the peer-reviewed Journal of Pain and Symptom Management.
Fernando says while has been a lot of research into so-called "compassion fatigue" in doctors, there has been very little into exactly how compassion works, and why it fails.
Many researchers have focused only on the idea that compassion runs out when doctors work too hard, use up their limited resource of compassion, and burn out.
That's only part of the story, says Fernando. He took a much wider view, developing a checklist of more than 50 possible barriers to compassion in doctors that ranged from "Feeling tired or fatigued" to "Patient is unkempt and malodorous" and "You are not sure if the patient will get better".
Boiled down, the results clearly showed there were three major barriers other than burnout:
- Distracting working environments (it's hard to focus on caring for a grieving family if your buzzer is going off every minute).
- Difficult patients (it's harder to remain compassionate if a patient is being rude or hostile or refusing to follow their treatment course).
- Clinically complex situations (the idea is that the doctor's brain switches into a more analytical and less caring mode as they try to understand an unexpected outcome or side-effect).
People working in healthcare generally are there because they have a strong motivation to help people, says Fernando, but sometimes there are so many hurdles it doesn't look that way.
"As doctors, when we experience distress or annoyance, it's very easy to focus on that. We're thinking, 'This freaking patient again?'
"What the patient will notice is that you have that look on your face. They can interpret that as 'no one really cares', when in fact you're frustrated because the treatment isn't working."
Fernando says it is important to understand the difference between empathy - which is the ability to recognise, and perhaps share in, the feelings or suffering of others - and compassion, which involves the crucial additional step of actually doing something to alleviate the suffering.
As a social species, humans have evolved to experience empathy and act compassionately, says Fernando.
"We don't have the wiring of snakes, who'd rather be alone and look after themselves."
When a doctor sees someone is suffering, feels that suffering and then acts on it, "it's a reflection of our true nature, which is that we're tightly connected with each other".
WHEN BURNOUT HITS
Anna Morrow, a general surgical registrar at South Auckland's Middlemore Hospital, experienced a serious absence of compassion in her intern year, after graduating from Otago's medical school in 2010.
The reasons weren't mysterious - burnout after underestimating how hard the job was going to be, and working month after month of punishing shifts.
"Work felt like such a drain that there was very little fulfilment or joy, which made it very hard to connect with patients," says Morrow.
"I know what kind of person I am. I want to help people and that motivates me, but I just couldn't get myself to do it. That's how I knew something wasn't quite right."
Things came right after some time off, some reflection and a change of role. But Morrow is still conscious of the day-to-day pressures that can cause compassion levels to dip.
Middlemore is in one of New Zealand's most culturally diverse areas, and many of Morrow's patients speak little or no English. It can get frustrating, she says, when someone is very unwell and you really need to communicate with them but an interpreter isn't available.
She has a little trick, though, for keeping herself in the right frame of mind even when she's 12 hours into a 16-hour shift, talking to the eighth person in a row with poor English, and she can hear herself starting to speak faster and lose patience.
She'll try to think about her parents, who are Korean and for whom English is a second language. She thinks: "If these were my parents, how would I want them to be talked to?" More often than not, it helps.
Fernando's research is only a first step. Coming next is a wider study across a range of healthcare workers, to figure out whether the reasons for compassion failure are different between, say, psychiatrists and GPs, or between nurses and surgeons.
The big prize, though, will be figuring out methods for actually boosting and preserving compassion levels.
Fernando says one obvious step would be to train doctors more explicitly about the barriers to compassion, so they can try to sidestep them.
What's particularly promising, though, is recent research suggesting anyone can boost their compassion by doing "mindfulness meditation" - exercises that help you to breathe calmly and become aware of the world around you right now, rather than fretting about the past and the future.
If that all sounds a bit Buddhist, that's because it is, kind of.
Fernando says trials at Stanford and Emory universities in the United States have shown experimental subjects taught versions of Buddhist meditations (you don't even need to sit cross-legged) found their levels of compassion increased. Fernando plans to conduct similar trials here.
"The studies were done on lay people not doctors, but there's no reason why you can't use those protocols to teach doctors and health providers."
Fernando says doctors routinely switch their minds into an "analytical" mode when they need to, and he believes it should be possible to teach them to do the same with compassion. When a doctor is feeling rushed, or their patient is being obnoxious, or they can't figure out why a treatment is failing, "that's when you have to flick the compassion switch".
There's another good reason for doctors to put compassion higher on their list of skills. Being compassionate is good for the doctor too.
Fernando still gets a warm glow when he thinks back to the occasion he gave that psychotic patient hope.
"When I do lectures to medical students and doctors, I ask, 'At the end of the day after seeing so many patients, how many of you reflect, and count the number of patients and families you have helped that day?'
"Very few will. But I say, 'Why not? It can sustain you.'
"It's a very stressful vocation. It will deplete us. But we're sitting on a goldmine in terms of our own self-care. If you reflect daily on the number of people you've helped or attempted to help, then you'll feel good, and realise it's worth the effort."
A COMPASSION CRISIS?
One person watching Tony Fernando's compassion research with interest is Kiwi anaesthesiologist Robin Youngson, co-founder of Hearts in Healthcare, a group lobbying internationally for health systems to place more emphasis on compassion and "whole patient" care.
Youngson said research shows doctors who are empathetic and who listen get better results in patients.
A recent study of 20,000 diabetes patients in Italy found those who rated their doctors as empathetic had 40 per cent fewer hospital admissions. He said the medical benefit of compassion had been shown to be more powerful than that of many medicines.
Yet Youngson said medical training appeared to be pushing things in the wrong direction - one study showed that despite arriving at medical school full of altruistic passion and a desire to help people, medical students had lower levels of empathy at the end of their training than at the beginning.
Youngson said "Hearts in Healthcare" wasn't rejecting any of the technological and pharmacological benefits of modern medicine - it was simply pointing out that when guided by compassion, a doctor is able to apply their technical skills and knowledge better.
He said compassionate care was about treating not just the physical needs of a patient but also their emotional, psychological and spiritual needs, and looking at the patient as a complex individual, rather than just a collection of symptoms.
Youngson agrees the secret for boosting compassion in healthcare workers may lie in teaching them the skills of "mindfulness", which means a doctor must "set aside all their busy-ness and distraction, and for every patient be fully present and listening - with all their senses".
- © Fairfax NZ News