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Presidential Address to ASMS 25th Anniversary Conference

Presidential Address to ASMS 25th Anniversary Conference

Dr Hein Stander

What I want to share with you today all started with a text message I received late one evening from a good friend of mine. We were both in a philosophical mood and relaxing with a glass of wine and exchanging a few text messages. He then sent me this question:

When did you last remember why you became a doctor?

When did you last remember why you became a doctor?

The question stuck in my mind for a few days but then got relegated to my subconscious due to the very same reasons I have not remembered why I became a doctor for a good few years now.

More recently I read a newspaper article on the Stuff news website that reminded me of that text message. The article’s heading was: “Cleaner swaps mop for stethoscope” and was written by Georgia Weaver. It relates the life story of Dr Jane Nugent.

She struggled at school. Was bullied. Never passed a single maths test, ever. At age 15 she left school. Her first job was cleaning hospital toilets. Not keen to do this for the next 50 years, she became a nursing aide. At times while making beds she dreamed of becoming a doctor but she really had no idea what that actually meant or what she had to do to become a doctor. At the age of 18 her mum encouraged her to become an enrolled nurse.

Years later, an experience with a patient made her reconsider her career options again. The patient was in a lot of pain and Jane asked the registered nurse on the shift if she could give the patient morphine. The nurse said that Jane needed to wait and in the interim she could give her patient some paracetamol.

Jane then decided that she wanted to be a registered nurse. She didn’t ever again want anyone telling her that she couldn't give her patient pain relief.

So she trained as a registered nurse, studying during the day and working as an enrolled nurse part-time at night.

Her drive to better herself led her to complete a Bachelor of Science at Otago University, majoring in pharmacology.

Later, while working as a charge nurse on a ward, an elderly woman had a fall. The medical consultant believed the woman was too sedated, but Jane’s working diagnosis was that the patient had nephrogenic diabetes insipidus and she set out to prove it.

Initially, the patient’s consultant was not convinced. However, two weeks later Jane was contacted by her to say she had made an appointment for Jane with the dean of the medical school to discuss becoming a doctor. Jane graduated from medical school in 2008, and went on to become a registrar in psychiatry but in the end missed hands-on medicine and changed tack and became a GP.

After reading the article, the question that my friend texted me months before resurfaced from my subconscious.

When did you last remember why you became a doctor?

It is clear that some of Jane’s career choices were driven by her desire to help patients. She had more than sympathy, which constitutes sharing in a person’s emotions, and more than empathy, whereby you have an understanding what a person is going through. She was driven by compassion, which adds a third dimension to sympathy and empathy. Compassion drives you to want to do something about the other person’s suffering or problem, to step in and help.

So what role and how big a role does compassion have within health care?

Compassion is a core requirement as stipulated by the New Zealand Medical Council. The publication, Cole’s Medical Practice in New Zealand, refers to compassion, or being compassionate, seven times. The most direct call to compassion is captured in the following statement: “Practise the science and art of medicine to the best of your ability with moral integrity, compassion and respect for human dignity.”

The lack of compassion is frequently mentioned in complaints by patients to the Health and Disability Commissioner. The lack of compassionate care was clearly identified as a contributing factor to the events at Mid-Staffordshire.

Humans are finely tuned to the presence or lack of compassion. It is not something we have to think about. We feel it instinctively.

So to practise with compassion is a requirement and an expectation from the Medical Council and our patients, and the lack thereof can lead to patient harm and complaints.

Is there any evidence that providing compassionate care can actually influence the outcome of care in a positive way, or does it just prevent harm and give everyone a warm fuzzy feeling?

Well, Dr Tony Fernando, an Auckland psychiatrist, experienced first-hand how being sympathetic and compassionate can save a life. In a recent newspaper article (Stuff.co.nz), written by Andrew Dudding, Tony describes how a patient’s psychosis was returning. At the time, the patient still had enough insight to know what was happening and what the return of the voices in his head meant. His partner was well aware of what the implications were and they were crying during the consultation. Tony was sympathetic and he himself became quite emotional. He was desperate to help his patient.

Later on his patient told him that Tony’s sympathy and tears stopped him from going home and ending his own life. He trusted that Tony and the health care system would help him and get him through this.

A recent study done in Italy of 20,000 diabetic patients showed that those who rated their doctor as being empathetic had 40 percent fewer hospital admissions.

So compassion can be very powerful and produce positive outcomes for our patients.

If compassion is such an important part of providing health care, why does it sometimes falter or disappear? How can Mid-Staffordshire have happened? Can Mid-Staffordshire happen here in New Zealand?

It is difficult to answer that unless you find the answer to the question: “How or why do health care providers lose their compassion or don’t engage in a compassionate way with patients?”

The more I read about compassion and learn about it the more some of the current challenges and failures we face and experience in health care start to make sense to me.

The underlying reasons for the lack of compassion are quite complex. Some are circumstantial or systemic.

Examples of how easily compassion can falter are not difficult to find.

A consultation or patient interaction is interrupted by a pager, phone call, knock on the door, or text message. This can prevent you from listening and really getting “into” the consultation.

Patients who are abusive or swearing challenge our ability to be compassionate towards them.

There are language and cultural barriers.

Time pressure; the next patient is waiting.

There are complex patients with complex clinical conditions. Doctors tend to switch to being scientists and pure clinical thinking mode and risk forgetting the patient behind the health problem.

I am sure you can think of more examples.

These factors or circumstances need to be recognised and addressed and we need to be mindful of how they influence our own practice and the care we provide to our patients. How do patients experience and perceive such contacts where compassion has taken a back seat? Unfortunately recurrent circumstantial lack of compassion can become the norm. “That is just the way we do things around here.”

There is a much more difficult condition to identify. It can affect any one of you in this room and in fact research would suggest that around 20 percent of you are at risk or are already having symptoms.

Compassion fatigue or secondary traumatic stress disorder is a well-recognised condition.

Who is at risk of developing this? What are the characteristics of the condition? How does it impact on the individual? Is there treatment for it and more importantly can it be prevented?

Frontline care-givers and helpers from all walks of life are at risk: care-givers in aged-care facilities, nuns, lawyers, nursing staff and doctors, to name but a few.

This condition has a far slower and more insidious onset. It is not the same as burnout but can co-exist with burnout.

Compassion fatigue manifests itself as physical, emotional and spiritual exhaustion. Sufferers experience acute emotional pain. While doctors with burnout tend to adapt to their condition by becoming less empathetic and more withdrawn, doctors with compassion fatigue tend to continue to give themselves fully to their patients but lose the satisfaction and pleasure from interacting with patients and in fact can become increasingly annoyed with their patients.

Symptoms can vary widely and red flags include:

· Abusing drugs, alcohol or food

· Anger and blaming

· Depression and less ability to feel joy

· Diminished sense of personal accomplishment

· Exhaustion (physical or emotional) and hopelessness

· Inability to maintain balance of empathy and objectivity

· Increased irritability

· Low self-esteem

· Sleep disturbances

· Workaholism

Quite often recovery is slow, the sufferer needing a month or two off from work, receiving treatment and a realignment of priorities, followed by a staged return to work.

Help includes:

· Developing interests outside of medicine

· Taking time for yourself

· Getting enough sleep

· Exercising and eating properly

· Identifying what's important to you

· Learning to reflect on a daily basis how you helped patients, and “banking” that feeling; and

· Mindful meditation

What not to do:

· Blame others

· Look for a new job, buy a new car, get a divorce or have an affair

· Fall into the habit of complaining with your colleagues

· Hire a lawyer

· Work harder and longer

· Self-medicate; or

· Neglect your own needs and interests

A number of years back Mother Teresa wrote to her superiors that it was MANDATORY for her nuns to take an entire year off from their duties every 4-5 years to allow them to heal from the effects of their care-giving work.

She clearly had insight into compassion fatigue and took steps to prevent it.

It is clear that we do not have unlimited supplies of compassion to give.

It is a bit like a bank account. You cannot keep withdrawing from it without making regular deposits into the account. Otherwise sooner or later you will end up with a zero balance. If you run out of compassion you cannot give something to your patients you do not have anymore. There are not a lot of compassion billionaires out there and we need to manage our accounts carefully, seeing that an overdraft is not well tolerated. When you make a withdrawal be sure to make a deposit again.

We have all seen the airline safety videos. When the oxygen mask drops from the ceiling put it on your face first. Help yourself first so you can then help others fit their masks. Quite often we are not very good at looking after our own needs first.

When did you last remember why you became a doctor?

My mind wandered further.

What role does compassion play from a health care manager’s perspective? What if I put myself in their shoes?

They have fiscal responsibility to make sure their budgets all add up and that the health care system lives within its means. They receive letters of expectation and contracts to deliver on and comply with. They deal with targets that need to be met, annual plans, regional plans and they need to implement and change systems to achieve all of this.

Reams of data come across their desks that need processing and interpreting. The problem is the spreadsheet for the laundry and salaries look no different to the spreadsheet for patient waiting times or unexpected clinical outcomes. The patient data have been completely stripped of any human factor, entirely dehumanised. You cannot feel compassion towards a spreadsheet full of dehumanised data.

To state the obvious, managers do not receive data on things that are not measured. How many patients are turned away from getting the health care they need and never make it on to a waiting list? How does that impact on that person’s life? Decisions are often made based on what is best for the system, but is it best for an individual whose health needs do not meet the criteria the system demands?

It is extremely difficult or near impossible for health care managers to have compassion towards patients. They are not given the time to think about it and they are not exposed to the frontline often enough to experience it.

So what role can we as clinicians play to compensate for this? How do we add value to management?

It is our responsibility to take the compassion we have for our patients into the meeting rooms and boardroom. It is more than that; it is our duty to take the compassion we have for our patients to the boardroom. If we don’t do it nobody else will.

Another thought crossed my mind. Does this perhaps give me an answer to something that has puzzled me for a long time? From time to time doctors label a clinical leader, clinical director, or CMO as having “moved to the dark side” or having become “one of them”. Although the “us and them” way of thinking is slowly being eroded, it still happens from time to time. But what triggers the labelling? There are no clear criteria for when a clinician has seemingly crossed that invisible line. We tend to have a “dark-side-mometer” built in and it suddenly, as if by magic, starts to register a signal. Is it possible that as soon as we perceive that a clinician has left their compassion by the bedside and not taken it to the boardroom, they get labelled?

To summarise: compassion is one of the pillars that health care and humanity is built on. Unfortunately we are experiencing an increasing demand on our time and compassion. It is becoming increasingly difficult to maintain our levels of compassion at the bedside as well as the boardroom. We are running an increasing risk of accepting that that is just the way we work around here and a lack of compassion becomes the norm.

The ASMS has a duty to make sure the MECA is adhered to and thereby provide us with every opportunity to practise in a companionate way and guard against working conditions that do not foster or encourage compassionate care. We need time to spend with our patients. An over-stretched medical workforce that is continually chasing targets in an environment of increasing fiscal constraint is not conducive to compassionate care.

On an individual level, we have a duty not only to look after our patients but also to look after ourselves and our colleagues’ health and well-being and guard against compassion fatigue setting in. We sometimes need to heal the healer. Put the oxygen mask on your face first. We need to be able to pause every now and then and reflect and remember why we became doctors.

Our patients deserve and expect to receive compassionate care. It is an expectation our health care system can ill afford not to meet.

When did you last remember why you became a doctor?

Ends

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