When a patient with obesity comes to my clinic, only one thought goes through my mind. Does this person acknowledge the real problem? You may call it insight. I try not to, because you cannot diagnose or elicit insight as there is no objective test for it. In short, you can be played for a fool easily. Compassion, like insight, cannot be diagnosed with certainty to be present or absent merely based on an interview or a supervised clinical encounter. Much of the greatest shows of compassion happens behind curtains, as it always has. Would it be fair to say that true compassion is when you hold a patient's hand and look into his or her tearful eye and communicate to him without words that you feel his pain of his life being cut down in the prime, that you feel her fear of the unknown while the diagnosis is still pending, or acknowledge the loneliness that the loss of his wife has thrust him into for the rest of his existence? Now, what about the water jug that you pushed nearer to him? What about the TV that you switched back on after talking to him? What about stopping talking to one patient and going over to the patient with dementia at the other end of the ward to help him into his slippers? Are they acts of compassion? Or are they merely fulfilment of your duties as a healthcare professional, expected of you anyway merely because of your presence there? Are they merely a demonstration of your sensitivity to the patient's physical needs that you perceive are a requirement of a civilised society that we live in? Did you do them because if you didn't the patient or the other patients on the ward would have noticed it? Would you have felt bad for the rest of the day if you had not done those deeds when required of you? Or would you merely tell yourself, "not the end of the world" and move on to your bed time reading on Waldenstrom's macroglobulinaemia? I see people not fulfilling these small gestures of comfort everyday. I do not judge them because I cannot be sure if it is merely a lack of awareness of their surroundings that resulted in inaction on their part. Nor can I be sure whether they can't be bothered because it would only slow them down further from the things that really matter, the things that are really "counted" these days, starting with discharge summaries and ending with VTEs.
Let us put compassion to the real test. A 25 year old girl with learning disabilities and minimal communication is admitted with vomiting, headache and skin rash. CT brain normal, A&E admits for ? meningitis having "done the needful" with ceftriaxone on flow. Medical SHO reclerks and desires a senior review for LP. Vague skin rash, glass test all done. CRP normal, mild leucopenia. No clinical signs of meningeal irritation. . Patient's father says, "I dont think she has meningitis, please don't do lumbar puncture on her" Registrar feels lumbar puncture is required. He also has heard somewhere that he has to act in the patient's best interests and not the father's best desire. He tells the father that the patient requires LP for medical reasons. LP attempted, fails. Anaesthetist called in, patient squirms, needs general anaesthetic for LP. Medical consultant comes in at this stage and says unlikely to be meningitis, no need for LP, stop antibiotics, go home. How do you as a reader feel all that went down? Was there a compassion issue here? Or was there only a medical experience issue? Was there only an issue of risk management or a pretest probability assessment? Was the consultant's decision the result of compassion informing knowledge or knowledge and experience influencing compassion? Do you think that the same registrar would make a different decision one year later when he becomes a consultant and has to deal with a similar case? Would he put his GMC number on the line for compassion despite the pervasive worry that this case could be meningitis although nothing else says it is? Is compassion being demonstrated when you make difficult decisions instead of the easy ones that would give you good sleep at the cost of bit of discomfort for the patient? Would every consultant have made that same decision? Do you the reader feel aghast that the consultant went out on a limb dangerously and is to be kept a close eye on for further failings? My point is, compassion extends beyond emotion and comfort. It is intricately hidden in many of our day to day clinical decisions. It cannot be measured because it is not evaluated for, specifically. Particularly by those who do not recognise it for what it is.
Assuming that we have established that compassion comes in various shapes and forms, visibly and invisibly, let us ask the more difficult question. "What then, is it that makes some people compassionate?" Or is the real question "what is it that makes some people WANT to be compassionate?". The difference is more than merely whether you look at it from the point of view of the receiver of compassion versus the provider of it. What I am really trying to understand is whether a person who shows compassion is purely driven involuntarily and intuitively to show compassion because he or she does not know anything different versus someone who wants to show compassion because they feel that not to show it would be unacceptable as an option, to society or to people in the immediate visible vicinity. An occasional encounter or an assessment while being observed for the eportfolio or an artificial setting where everyone is on their relaxed best behaviour will not distinguish between the two drivers. On the other hand, a long term knowledge of the personality of the person and his or her interactions with other colleagues could provide us with an idea of which of the two drives his compassion. To split hairs further could remove the fun for those engaging superficially with this concept and hence I will leave it at that level for now. For those wanting some intellectual take on this, have a look at "compassionate care: the theory and the reality"
Is a compassionate clinician more effective in today's and tomorrow's world of medical care? I would like to pursue that question further but I am aware of the increasing length of the blog. I haven't checked the current requirements for admission into medical school but I am fairly certain that being compassionate or being able to be compassionate is definitely not an essential requirement. After all, we can teach them how to be compassionate after spending 5 years in medical school can't we? If you believe that, you are likely to merely see sarcasm in what I write and nothing beyond. You may even be contemplating a school to convert terrorists to be ambassadors for their country. At the end of the day, the real question remains. "Can we make non-compassionate people compassionate?" Or more realistically, "is amplifying the compassionate feelings that lurk in the subconsciousness of good people, tuning it up to increased sensitivity and awareness, the best we can hope for?"
So if we believe that compassion can be taught in medical school or acquired at the workplace over time, how are we making sure that it happens? When was the last time you thought at the end of a trainee's posting; "that trainee has become more compassionate over the past four months here"? These days there are very few opportunities for anyone to get a feel for anyone's compassion on a day to day basis. The amount of exposure to each other, whether nurse-doctor or trainee-supervisor is so minimal that generic skills are increasingly assumed to be present in people based on their interactions with you. How does a person / doctor behave when they have nothing to gain from the other person? When there is no fear of negative feedback? When there is no need to impress another? When there is no desire for reassurance from others? When showing compassion is more likely to slow you down in your work? When showing compassion is unlikely to be appreciated by anyone {imagine one to one with a dementia patient behind a curtain}? When showing compassion can put you at risk of censure? {see case example above}. In one sentence, true compassion cannot be assessed, because you are never there when it happens. We just live in hope that we have the right people in the right jobs. When we start suspecting the absence of true compassion, we will convert hospitals and nursing homes into big brother houses to enforce compassion. The problem is, we convert a fine human sentiment into a duty of care that takes away the pride that good people get from its delivery. There is no going back if that happens.