We don’t have to take off our compassion, or our ability to show it, when we drape a stethoscope around our neck. The need for doctors to be professional is not synonymous with being emotionless.
Long ago, when I was an intern at an adult teaching hospital there seemed to be a tradition that consultants spoke to their privately insured patients but left communication with their ‘public’ patients to the inexperienced junior staff. Family members who wanted to know about their loved one’s condition could come to the hospital’s front foyer once per week and ask to see the intern.
We recent graduates had mastered voluminous facts in our medical course, but I can’t recall a single time when we were taught how to communicate with patients in a way that was sincere and gentle while at the same time authoritative. True, we were taught to ask questions as part of the medical history taking, but there was no instruction about how to ask or answer difficult questions about life and death, or even more innocuous questions about the patient’s circumstances and how this may interact with their understanding and desires in relation to their illness. We were instructed to take a ‘social history,’ but this was limited to asking about alcohol and cigarette consumption, with no instruction about how to use this information other than to record it in the notes.
In my first few weeks I would ask patients about their family circumstances and what their concerns were, but I soon learned that this approach made it take much longer to get through the work and that questions like these presented a series of problems to which I had no answers.
In my third month after graduation, I assisted at an operation on a fit, active, 54-year-old man who had a hard lump around his navel. The surgeon opened his abdomen and found widespread cancer that had spread to the man’s liver. The surgeon closed the wound. There was nothing to be done.
That afternoon happened to be the one when family members could ask to meet the intern. It was my job to tell the man’s unsuspecting wife that her husband had widespread cancer for which there was no treatment. I told her the truth as kindly as I could. Her eyes welled up with tears. So did mine.
Afterwards, I felt embarrassed about my show of emotion. Why couldn’t I be more ‘professional’ like my consultants. I wondered if I was really suited to do medicine. Later, I realised that it may have helped her in a small way. She may have seen that although the news was bad, the person who gave it cared.
In subsequent years, when I was a consultant, my eyes would sometimes moisten when I had to tell a parent that their child would not survive. And sometimes it happened when I had the pleasure of giving unexpected, joyful news.
Was I being ‘unprofessional’? Or is there room for families and patients, for medical students and junior doctors to realise that we, their seniors, do care? I heard the description of balancing between aloofness and overfamiliarity, as being similar striding along a narrow catwalk. But it’s not that narrow. There is a place to show humanity and to let people know we care. It’s not ‘unprofessional’.
Of course, there are some professional boundaries which we must always respect. Boundaries which prevent us from offering unrealistic expectations, from acting in ways which are of dubious legality and from confusing personal and professional relationships.
However, these well accepted boundaries are different from really caring about our patients and doing something about it. Gordon Schiff a Harvard physician argues that too strict an interpretation of professional boundaries “risks encouraging detached, arms-length, uncaring relationships” with this type of bounded thinking serving “to rationalize abdication of our professional and personal responsibilities to humanely respond to patient suffering and underlying injustices”.
We don’t have to take off our compassion, or our ability to show it, when we drape a stethoscope around our neck. The need for doctors to be professional is not synonymous with being emotionless.
Medical schools are now much better at teaching communication. But in the real world junior doctors mainly learn this skill, for better or worse, from their seniors. There is far more to good communication than just being nice to patients. It is about being kind, thoughtful and compassionate. This has implications for the quality of patient care.
It is now 10 years since a public inquiry into the UK Mid Staffordshire Hospitals found that patients had died from avoidable causes and that many more suffered unnecessary indignities and harm. The report concluded that there was “an apparent lack of compassion among healthcare workers” at the hospitals. The expert panel formed to respond to the inquiry findings recommended that the quality of patient care, especially patient safety, must be the aim above all others. In view of this priority, it recommended that patients and their carers should be engaged, empowered and heard everywhere and at all times in the health system and that clinicians and administrators must insist upon, and model in their own work, thorough and unequivocal transparency in the service of accountability, trust and the growth of knowledge.
These are powerful recommendations, not just for healthcare but for life in general: listen; model transparency; model trust; keep on learning.
Kim Oates is an Emeritus Professor of Paediatrics, a former CEO of the Children’s Hospital at Westmead, a former President of the International Society for Prevention of Child Abuse and Neglect and an elected Founding member, International Academy of Quality and Safety.
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