‘A crisis in caring’: a place for compassionate care in today’s medicine

Often during a busy ward round, it has become commonplace for names to ‘escape’ doctors and instead the patient’s underlying disease replaces their identity, e.g. ‘Mr Malignant Melanoma Fractured Right Shoulder’, ‘Miss Left Subarachnoid Haemorrhage’. Hippocrates, our forefather in medicine, famously quoted that ‘it is more important to know what patient has a disease, than what disease the patient has’. Unfortunately, in current clinical practice, this ethos has been severely neglected and compassionate care for the patient sidelined, instead replaced by a preoccupation with disease management, administrative obligations and academic pursuits. ¹

Compassionate care is well known to be associated with a multitude of benefits including improved patient satisfaction, treatment compliance, fewer malpractice complaints, improved clinician well-being and professional satisfaction.^2–7 It is also part of the requirement for doctors in the General Medical Council's (GMC) ‘Good Medical Practice’, which stipulates that doctors should listen to patients, take account of their views and practice sensitivity and consideration when providing support to patients. ⁷ Therefore, with benefits conferred to both patient and doctor, it is inexcusable not to implement compassionate care into current clinical practice. Every measure should be taken towards encouraging and fostering an environment of compassionate care in the workplace and throughout medical education and training.

Arguably, the fairly recent implementation of communication skills as a mandatory component to pass medical school could be thought to address this, at least in part. However, on the contrary, despite this intervention, a desensitisation process has been found to take place for the majority of medical professionals at some point during their medical training.^8–10 This gives one the impression that communication skills’ training seems to only teach one to ‘wear a mask of detached concern’ or ‘smile through clenched teeth’ instead of cultivating true compassion. ⁶ Studies have shown that the degree of compassion shown by medical students progressively declines over their course of training, most markedly during their final clinical years.^8–10 It is certainly ironic that the closer a medical student is to becoming a doctor, the less compassion they have left for the patients they will soon treat. In a similar vein, professional experience and seniority in medicine have been associated with desensitisation towards the pain of others, with junior clinicians empathising with the pain of others more sensitively than their senior colleagues.^6,9

Why does it seem that with more knowledge and experience, the less a doctor seems to ‘care’ for their patient? Does this mean that knowledge breeds contempt? ¹ While contempt is unlikely to be the prevailing thought of senior clinicians, it is more likely that with time, one unknowingly applies less compassion in the care of the patient, especially when caught up with other aspects of the patient’s management, work commitments and emphasis on academic pursuits.

Current health services are highly pressurised environments with doctors needing to work long hours delivering direct patient healthcare and also have to shoulder the repercussions of clinical and administrative staff shortages.^6–9 Doctors who worked the highest number of ‘on-call' shifts were found to experience higher levels of ‘compassion fatigue' and had higher incidences of illness and sick leave, which demonstrates the impact of undue stress on the ability of doctors to empathically engage with their patients. ¹¹ This was translatable across all specialties, whether medical, surgical or emergency medicine. ¹² General practitioners, the front line of the NHS and frequently having to deal with the holistic care of the patient, unsurprisingly were found to have the highest levels of compassion among all specialties; however, they were also found to experience a very high rate of burn-out with female doctors found to be prone to ‘compassion fatigue' more so than male doctors.^11–13

Maintaining appropriate levels of compassion is undeniably challenging, especially given the current climate of a disgruntled workforce and over-burdened services which are less than ideal to engage empathic processing. ¹⁴

Compassion-cultivation programmes including mindfulness have been found to have excellent results when implemented in medical schools in cultivating compassion when compared to communication skills training programmes, and the effects were sustained.^15–19 Future consideration should be made to apply similar programmes in both medical schools and for current doctors as part of their annual competency assessments, to serve as a gentle reminder not to only focus on the science, but also the ‘art of medicine’.

In 2012, HRH Prince Charles wrote a guest editorial in the Journal of the Royal Society of Medicine declaring a ‘crisis in caring.’ ²⁰ This was in response to the shocking findings of the Francis Report revealing sub-standard patient care and increased mortality rates. This was a real example of the devastating effects of practicing medicine with corroding compassion. It is undeniable, however, that the current challenges doctors are facing would to some extent impact their ability to engage with compassionate practice. Although it is understandably easy to get disillusioned under these stressful circumstances in medicine, one must always take a moment to remember not to neglect the patient in front of you. Remembering there is an actual person and not only a pathology to be treated.

In understanding that the secret in care of the patient is in caring for the patient, we as doctors would be taking that one crucial step closer towards fostering humanity, and more importantly, finding the deserved permanent place for compassionate care in today’s increasingly dispassionate medicine. ¹