Compassion: It’s not all about the doctor

In the growing global conversation about compassion in health, the doctor (or the nurse) is unsurprisingly prominent. We see troubling news reports of patient suffering and neglect and wonder “How could they let that happen?” Given it is the doctor who appears to have failed in their duty of care, such questions seem both necessary and reasonable.

A similar focus is also evident in research, most of which is conducted under the “compassion fatigue” banner. However, while studying compassion fatigue has highlighted burnout in our healthcare systems, this focus has also blinkered us to the fact that compassion is powerfully influenced by factors that are well beyond any doctor’s control.

In most sciences, interventions follow from the factors seen as causing the problem. In medicine, we treat doctors and nurses as the root cause of a lack of compassion. Commensurately, we debate different selection criteria in our medical schools, whether there should be more compassion training, and if we should provide greater rest/recuperation. Such conversations are clearly worth having. However, they also obscure the self-evident fact that healthcare professionals are only one piece of the overall compassion puzzle.

Like all compassion, medical compassion has its origins in the evolutionary processes that resulted in humans naturally caring for the young or taking mutual care of their group.

Accepting that “medical” compassion is subject to the same influences that govern everyday compassion suggests a unitary focus on the physician which is inaccurate, unhelpful and obscures other important considerations.

While compassion in medicine is expected and a legal requirement, everyday compassion is optional and celebrated. The NZMA Code of Ethics lists 12 principles and requires that physicians “Practise the science and art of medicine to the best of [their] ability with moral integrity, compassion and respect for human dignity.” So in health, compassion is obligatory, repeated and compensated while non-medical compassion is unexpected, voluntary and infrequent. The effects of repetition, compensation and obligation on compassion in medicine are unknown.

As well, like all behaviour, medical care happens in particular contexts. Doctors work in demanding environments, with shorter appointment times, frequent interruptions, pressure to maintain electronic records and the like. How many of us have experienced our doctor frantically typing or answering the phone during an appointment? Does this help compassion? It seems unlikely and the systems in which we expect our doctors to work do not naturally lend themselves to care.

Finally, we need to talk about ourselves – the patients. All compassion is expected to occur in the relationship between a helper and the person in need of help. To think that the characteristics of the person seeking help are not relevant is naïve. Evidence shows that empathy – a response related to compassion – declines across medical training, dropping precipitously during the clinical years when junior doctors start dealing with patients. A coincidence? Perhaps. But our own experience tells us that it’s more difficult to care for some people. Do we care more or less for the friend who consistently gets into destructive relationships? The spouse who complains of toothache while refusing to go to the dentist? The student who is repeatedly disorganised but seeks an extension?

Theoretical models suggest compassion systems are not designed to be limitless. Neither are those of our doctors. And yet, in medicine, we expect physicians to care even when patients are demanding, insulting or unappreciative or when their suffering seems self-inflicted (such as lung cancer following a lifetime’s smoking).

Certainly, doctors should strive to be compassionate to all, but the type of patient does play its part. In experimental studies we’ve conducted, we’ve found the effect of the patient on whether their doctor is compassionate is up to six times more important than any other factor. Six times!

This is not a question of blame. Rather, it’s a question of recognising that the natural capacity to care does not mean that compassion systems lack checks and balances.

So, yes, doctors need to think about compassion, but so do patients. Yes, we need to train our doctors to care but we also need to think about how our healthcare systems affect compassion. The lack of compassionate medical care is a systemic problem that requires systemic thinking and systemic solutions. It’s not all about the doctor.