Room for Compassion in Medicine?

[Cranial Gavage]

Posting new thread to prevent hijacking a different one.

My question originated from the "worst part of med school" thread, in reference to the comment posted below:

Also I resent the nonstop propaganda of compassion over all else.

Question (as an MS-0 myself):

How would other med students respond to this quote? Agree or disagree?


Responses from the other thread:

Agree

I would probably agree with this.

Most of the lecturers that champion compassion "over all else" are not practicing physicians. Most of them are PhDs in things like English lit or philosophy or medical ethics.

The problem with those people who keep pushing compassion "over all else" is that they don't seem to understand what compassion, in a clinical setting, really means. The way they talk, you would think that true compassion is giving in to your patients and giving your patients whatever they want.

But giving into your patient's demands isn't necessarily what's best for that patient. If your patient comes in demanding percocet, just giving him as much percocet as he wants isn't good for him. But these BS lecturers would have you believe that, in fact, you should give him some percocet "because the patient knows what's best for himself!"

I don't resent it. To me, it isn't first as in, "above" all else, it is first as in, "below" all else, as in - foundational, and therefore first. I believe they are trying to get us to operate with compassion as a foundation from which we make our decisions, which isn't the same thing as "above all else".

Agree, especially with SMQs take on it. It's not that I'm a jerk who doesn't think compassion is a good thing, it's that the people who are speaking the loudest about it usually have a very narrow, not clinicially based view of what it means. You have to go to these lectures, but you really learn the ethos of your profession on the wards from preceptors and residents you admire.

Anka

These lecturers I find are usually present in years 1 and 2 of med school.

If I had tried applying even half of what they were promoting in my 3rd year, there's no doubt in my mind I would have been berated endlessly (especially on a rotation like surgery)

What kinds of "compassionate" attitudes/behaviors cause trouble on the wards or in surgery?

I wouldn't have gotten in trouble for following what they told me in those "touchy-feely" classes, but it wouldn't have helped me out.

For instance:

Lesson 1: Try to find out your patient's motivations for doing things.

Yes, very easy to do in the abstract, where all your patients are good people who tell the truth. When they have something to hide, trying to find out their motivations is like pulling teeth. And it takes up a lot of time - time that you need to do other stuff.

Lesson 2: Try to reach a compromise with your patients on ALL treatment decisions!

Sorry, but if a patient asks for percocet because he thinks he might "need it when he gets home," then I'm not going to try to compromise. There isn't a hospital in the world that's going to give you percocet for your recent bout with the flu.

I know that you want to deliver in a birthing pool, but I'm afraid that we don't have one at this hospital. We don't even have bathtubs in this place. I have no idea why you came here, as opposed to the birthing center down the street.

I know that you don't want an IV, but if you want to deliver in this hospital, then you need one. That way, if you start to hemorrhage or if you need a stat c-section, we aren't left up **** creek without a paddle. It's for the best.

Lesson 3: Try to respect your patient's needs!

A lot of patients need to just "suck it up" sometimes. I'm sorry, but the hospital doesn't have a special kind of organic yogurt that you "need" in the mornings. You'll have to settle for Dannon. And no, asking my resident to "pull a few strings with the cafeteria" is only going to bring ridicule and laughter onto me. Sorry.

Lesson 4: Your patients know more about disease than you do.

Maybe - but your patients know more about THEIR disease than you do. They don't know more about ALL diseases than you do.

We had a panel of women with ovarian cancer come talk to us. They said that one of the common symptoms of ovarian cancer is "abdominal discomfort and bloating," and they were angry that more doctors weren't very aggressive about suspecting ovarian cancer in women with "abdominal bloating."

Jesus Christ. Do you know how many diseases have "abdominal bloating" as a symptom? PMS, IBS, IBD, constipation, anxiety - the list is endless. Am I going to jump to a diagnosis of ovarian cancer in every woman who thinks that she's "bloated"? No, not even as an ob/gyn. I'm sure that these women thought that they were giving us an important diagnostic clue, but it truly wasn't helpful.

In the first two years, they basically try to teach you that compassion is more important than everything, including common sense. And that's just not true.

smq- nice response, thanks for posting.

Well, I think that it's really that these lecturers don't define compassion very well - or else they themselves don't know what compassion really means. It does NOT mean being a pushover, or letting your patients run over you and make all their own decisions themselves.

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[Cranial Gavage]

Ok, now my quote button will go on sabbatical for a while.

To rephrase my question-

Are the notions of empathy, compassion, and "making a difference" unrealistic ideals that cannot survive the colder realities of practical medicine?

 

[smq123]

Are the notions of empathy, compassion, and "making a difference" unrealistic ideals that cannot survive the colder realities of practical medicine?

(Sorry, I know I keep posting in response to this.)

Cranial - No, "the notions of empathy, compassion, and 'making a difference'" can survive the practice of medicine.

The problem is, people who don't practice clinical medicine (including pre-meds) do not have a clear idea of what empathy, compassion, and "making a difference" truly mean.

"Making a difference" does not mean that you'll save everyone. You'll save some people's lives, but not everyone's.

Compassion, in my mind, is caring for people who suffer - which is not the same thing as caring for people who, in their OWN mind, are suffering.

The woman who wanted special organic yogurt? Not suffering.
The woman who just miscarried? Suffering.

The woman who wanted to go home with percocet after her upper respiratory infection ("just in case" she had pain)? Not suffering.
The woman who wanted to go home with percocet after her total hysterectomy? Suffering.

The thing is, what they taught in first year is that if the patient thinks that he/she is suffering, then their pain is always valid. And that's not really the case.

 

[deleted77919]

I think a number of the posts reflect students frusterations with the way "compassion" is taught at medical schools. Talking about feeling a patient's pain is not going to take a cold hearted bastard of a medical student and make him cry rainbows and fart sunshine. Students who are already in tune with empathy and sympathy don't benefit either.

By the time students arrive in medical school the way they relate to others on a basic level is already formed and an empathy course is not going to alter that. Techniques and practice delivering bad news? Good use of time. Trying to teach "caring" ? Not so much.

 

[PeepshowJohnny]

"Are the notions of empathy, compassion, and "making a difference" unrealistic ideals that cannot survive the colder realities of practical medicine? "

At the core, of course not. I try to feel empathy for my patients, treat them compassionately, and do try to make a difference in their lives, as corny as it sounds.

However, as others have eluded to, the way this stuff is taught first year is all wrong because it idealizes the patient.

The scenarios where the patients complain about untreated pain never involve drug seekers.

The scenarios about the "difficult" patients are always resolved by a simple, polite conversation.

However, these are not the case in real life. As other's have alluded to, life is never this nice and pretty. You have drug seekers, you have to deal with patients with personality disorders that seem like they leaped off the page of the DSM who will get on your last nerve everyday.

The thing is, I do try to be compassionate and empathetic, but not in the way the idealist academic philosophers outline. Somebody's a drug seeker, I feel sorry for them that their coping skills and life are so screwed up they need a narcotic to handle, I feel sorry for the nerve-grating patients because their personality is being amplified by the stress thy're under. Likewise, I may get pissed off having to deal with getting another have demented octogenarian into a nursing home, but I still feel compassion in my actions and inner most feelings even if my brain is pissed off.

If I could sum it up, I'd say first year is simplistic. Everything can be listening, talking, and understanding. Most of the issues you'll see in a hospital setting are so old and complex that NOTHING you can do can fix them. But that shouldn't stop you from being empathetic and compassionate.

 

[Slide]

Compassion means different things to people. The ph.d professors often hear about the ills and the bad sides from the reality of medicine. To them, compassion involves fixing these things, which may include helping some patients get their fix of oxycodone for "post-surgical pain". The clinicians, of course, know the realities of medicine and have a different view of it. Compassion is about caring for the general well-being of the patient, not about catering to the patient's needs.

 

[beefballs]

I just wrote a long explanation to you, but then deleted it because I don't want to prejudice your views. Suffice it to say there are some things I don't believe can or should be taught in a traditional sit down lecture hall, and I don't feel it is the place of a professional school to attempt to interject their values into a captive audience. This is not to say that certain things aren't valuable or have their use, but I resent the single minded "with us or against us" attitude that many of these professional development courses have. Again, this is my opinion and intelligent people can & will disagree, but I believe we would be better served with classes on the economics of medicine, legal & public policy seminars as to how it relates to the current practice of medicine. I literally have courses where I have to read story after story about topics such as the terminally ill, losing a loved one, the pain of losing a patient etc and I find them to be an enormous waste of time with little to no practical educational value.
Good luck with school, I actually enjoy the coursework for the most part and feel most of my classmates are stand up people an hope you have a good experience

 

[bubbachuck]

i would imagine that a lot of schools have modified their curriculum of ethics courses to reflect clinical realities. my school's 1st year ethics course was actually really balanced in teaching ideality and reality. for example, scenarios involving patients who refused blood transfusions due to religious beliefs, then complicated by if it was a child whose parents had the beliefs. we also discussed painkiller-seeking drug addicts and non-cooperative patients. in addition we had regular PBLs where we would discuss ethical scenarios with practicing physicians.

 

[roja]

Ok, now my quote button will go on sabbatical for a while.

To rephrase my question-

Are the notions of empathy, compassion, and "making a difference" unrealistic ideals that cannot survive the colder realities of practical medicine?

No. They are not. They can survive. But like all things, sometimes it takes work. There are some days where it is harder to keep these in things in mind. Those days where I am in the ED and I am seeing 6-7 patients an hour, with some of them critically ill, others being abusive and rude to staff, others being demanding and irrational, and the occasional confrontation with something that no one can fix and has ended up bad.

There is compassion 'fatigue'. You can't be compassionate, empathetic and trying to make a difference every moment.

But you can try. And you can vent when you have had a bad day. And you can do things to help with your mental well being, which helps with decreasing cynicism and misery.

If you are interested in this topic, you can look at the AAMC and ACGME (the governing bodies of medical schools and residencies). There are many people who have developed 'wellness curricula' and this is one large component of it.

 

[78222]

I agree with most of the posters here. Sure compassion can survive in medicine. I don't think anyone here is arguing that it can't. The problem is simply the way they try to cram fake empathy down our throats in the first two years. It's ridiculous and does nothing to make people who started medical school lacking empathy, develope it and for me at least, with my contrarian streak, it makes me want to distance myself from it.

 

[OncoCaP]

I'm fine with compassion; I don't have a problem with professors preaching it. It's something I can actually do for the patient that my preceptors and attendings sometimes don't have the time or bandwidth for. We really don't know enough to do much for the patient that someone else isn't already doing and doing much better than a beginner can. Many patients seem appreciate someone who cares although they strongly prefer someone who can actually solve their problem.

 

[soeagerun2or]

The listed ideals are fabricated by the AAMC and medical school administration to create a sense of mysticism around the physician and create qualities that are possessed by a physician but not (at least not all) by other ancillary medical fields. It is unfortunate that the policy setters feel the need to hoodwink the public and feed them a "feel-good" load of crap.

Rather than making the patient feel good by ensuring that we as care providers are human as well perhaps our efforts would be better sent on creating and being the cures the public looks to us for.

 

[erica31]

In relation to smq's posts... I don't think compassion is giving patients unnecessary percocets... I do think compassion is understanding the awful truth that this person for whatever reason is going down a dangerous narcotic-driven road.

No one wakes up as a young child and thinks.. oh boy, when I'm 30 I'm going to be a junkie! Yay! People's lives takes unfortunate turns of events... and for whatever reason (homelife, lack of willpower..), and it doesn't matter... this is where the patient ended up -- in an ER seeking narcotics. I feel compassion very much for this type of person -- while I as a future physician am going to refuse giving the drug, I will go away and finish the rest of my day peacefully, while this person will likely be in psychological or physical torment for want of this drug.

Furthermore, I am not saying compassion is stopping what you are doing at that very second, and trying to enroll the patient in NA or get them to rehab.. but compassion, as I would define it, is the ability to feel inside our heart, that tiny twinge of sadness for our patient...

 

[smq123]

Furthermore, I am not saying compassion is stopping what you are doing at that very second, and trying to enroll the patient in NA or get them to rehab.. but compassion, as I would define it, is the ability to feel inside our heart, that tiny twinge of sadness for our patient...

Of course. I still feel sad for them. Who wouldn't? Obviously, no one wants to be a junkie.

But no one wants to be lied to. No one wants to be backstabbed by a drug-seeking patient who tells the nurse that YOU "lost" their narc script. No one wants to have the nurse then report you to your attending.

This is what is so frustrating about the MS1 and MS2 classes on "empathy." Most med students and doctors STILL feel at least some sadness for their patients, no matter how frustrating the patient is. What nobody tells you in those classes though, is that you will experience a MIX of emotions. A very, very, VERY complicated mix that is difficult to navigate.

And that's why those classes were such a friggin' waste of time. How do you deal with feeling sad, frustrated, angry, hurt, betrayed by your patients, and tired all at once...on a daily basis? No one addressed that. They'd just cheerily chirp that it was important to "discuss our feelings," but what if your feelings are so mixed and so profound that you can't find the words to discuss them?

But no one wants to be lied to. No one wants to be backstabbed by a drug-seeking patient who tells the nurse that YOU "lost" their narc script. No one wants to have the nurse then report you to your attending.

Trust me, I also know that people's lives can take unfortunate turns. If I didn't know this before, I would definitely know it now after doing my psych and internal med rotations. That was one of the things that I loved about med school - people have amazing stories, and it is a privilege to be able to hear these stories. It doesn't mean that you won't get frustrated and angry, though.

 

[erica31]

Agreed.

But I think Anger and Frustration are a part of compassion. Compassion involves feelings...

A person that just "didn't give a &*$#" -- that is (at least with how I define it) non-compassion.

And I think you hit upon an important topic "feelings are so mixed and profound you can't finds words to discuss them"... that is likely why the courses med students take seem useless. People can't find the right words to discuss them, let alone teach about them.

I likely will become jaded at times during my training... I already have, and that was simply during my stretch as an EMT. (A blue tongue from sucking on a blueberry popsicle is NOT a reason to call for an ambulance!!)

I just hope that I, along with my peers, will maintain enough insight, compassion, big-picture-view, that when compassion truly is necessary, I will not have lost it along the way.

Of course. I still feel sad for them. Who wouldn't? Obviously, no one wants to be a junkie.

But no one wants to be lied to. No one wants to be backstabbed by a drug-seeking patient who tells the nurse that YOU "lost" their narc script. No one wants to have the nurse then report you to your attending.

This is what is so frustrating about the MS1 and MS2 classes on "empathy." Most med students and doctors STILL feel at least some sadness for their patients, no matter how frustrating the patient is. What nobody tells you in those classes though, is that you will experience a MIX of emotions. A very, very, VERY complicated mix that is difficult to navigate.

And that's why those classes were such a friggin' waste of time. How do you deal with feeling sad, frustrated, angry, hurt, betrayed by your patients, and tired all at once...on a daily basis? No one addressed that. They'd just cheerily chirp that it was important to "discuss our feelings," but what if your feelings are so mixed and so profound that you can't find the words to discuss them?

But no one wants to be lied to. No one wants to be backstabbed by a drug-seeking patient who tells the nurse that YOU "lost" their narc script. No one wants to have the nurse then report you to your attending.

Trust me, I also know that people's lives can take unfortunate turns. If I didn't know this before, I would definitely know it now after doing my psych and internal med rotations. That was one of the things that I loved about med school - people have amazing stories, and it is a privilege to be able to hear these stories. It doesn't mean that you won't get frustrated and angry, though.

 

[smq123]

But I think Anger and Frustration are a part of compassion. Compassion involves feelings...

A person that just "didn't give a &*$#" -- that is (at least with how I define it) non-compassion.

Some of the professors implied that compassion and anger/frustration were mutually exclusive.

This is (partly) why I hated those classes. The people who said crap like that clearly had no experience to draw upon, and had no clue what they were talking about.

I likely will become jaded at times during my training... I already have, and that was simply during my stretch as an EMT. (A blue tongue from sucking on a blueberry popsicle is NOT a reason to call for an ambulance!!)

That's not being jaded. Trust me.

What you described is just frustration at someone's lack of common sense.

For me, being jaded is believing, before I even see the patient, that he's going to be a difficult patient to deal with. And treating him as if that's the case.

And I think you hit upon an important topic "feelings are so mixed and profound you can't finds words to discuss them"... that is likely why the courses med students take seem useless. People can't find the right words to discuss them, let alone teach about them.

They just made me angry. They just simplistically claimed that you COULD (and that, in fact, you SHOULD) discuss these feelings, while having NO FRIGGIN' CLUE how hard it would be. It's like a non-health care worker telling you to just "put a bandaid!" over an arterial bleed. Totally ineffective measure against something that goes pretty deep.