I was standing at my patient’s bedside. Mike Venata was having chills with a temperature of 103. Sweat covered his balding scalp like dew, then coalesced and rolled down past his staring eyes.
Just 20 minutes earlier, a specialist had informed him that he had metastatic pancreatic cancer and could expect to live less than six months. He was alone. I’d seen him once before; as an infectious-disease specialist, I’d been called in because his fever might be due to an underlying infection.
I wondered: How do I show him compassion?
Many say our health-care system lacks compassion. I too at times feel that pills and surgeries, CT scans and radiation therapies, biopsies and blood tests have become a priority in medicine and that compassion — the “touchy-feely” part of medicine — has become an afterthought in patient care.
After a few days in the hospital, Mr. Venata’s fever subsided, and I asked if I could talk with him about his experience. He was a retired major who earned a Bronze Star in Vietnam, then became an executive for a multinational company, from which he had recently retired. He had never been married. I wanted to talk to him about how doctors should handle end-of-life situations.
I asked, “When you were told your diagnosis of the cancer, what went through your mind?” Sitting by his bedside, I expected to hear the usual description of shock or denial. But his case was different.
“Well, the first thing I wanted to do was — I wish I was 10 years younger, I would have reached across and slapped the [expletive] out of the doctor.” Despite his words, he didn’t look angry, just deeply saddened.
Startled, I asked why.
He told me that the specialist had pulled out a piece of paper with his biopsy results and said, “ ‘Well, this isn’t very good. This is terminal.’ . . . He didn’t talk to me, he talked to a piece of paper. I got a guy sitting here reading the piece of paper telling me I am going to die [then] walking out the door. That was not well executed.”
To him, the heartlessness of the doctor’s presentation was as painful as the news.
Hearing this scathing critique, I broke out in a sweat. I could easily imagine myself on a busy day informing a patient that his or her blood test was positive for HIV, while at the same time my cellphone is ringing, the emergency room physician is waiting for a return call and I have to hurry to my clinic where two other patients are waiting in examination rooms. And to be honest, I make terrifying diagnoses every day. I fear that in such situations, I might not be as compassionate as my patients might like.
Compassion is one of what I call the four C’s; along with competency, communication and convenience, these are things patients should be able to expect from their doctors. Compassion and communication skills are part of a good bedside manner, something that medical schools strive to teach.
I am sensitive about the issue of compassion because even my own parents at times feel I am a bit abrupt with them regarding their health questions.
Some months ago when my mother had a rash, she decided to query my wife, who is also a physician, even though her symptoms were in my area of expertise, infectious diseases. So half-jokingly I asked her why she hadn’t consulted me.
“Because you don’t have time to listen,” she said matter-of-factly.
A few weeks ago, I spoke to William Branch, an internist and professor at Emory University School of Medicine in Atlanta. For two decades he has been conducting studies to see if we can teach physicians to be more compassionate.
Like a father figure, he reassured me. “Our health-care system does not lack compassion,” he said. Yet he acknowledges that expressing compassion has been a challenge for doctors because of managed care, large patient volumes and electronic medical records.
Compassion cannot be taught in a single training session, he added, but it can be taught.
In research conducted at five medical schools and published in the journal Academic Medicine in January 2009, Branch studied two sets of faculty members on their skills at being compassionate as evaluated by their medical students and residents. The students watched the faculty members’ interaction with patients, judging those interactions and also how well they taught caring skills, by example and by lecture.
One faculty group underwent a two-year program of Branch’s design that combined experiential learning of skills such as role modeling along with reflective exploration of values through writing narratives and other activities. The other group had no intervention.
I was heartened to know that the compassion-training group was rated significantly more compassionate or humanist with their patients. And his was not the only study on the subject.
Compassion can be taught, I told a class of medical students — but it also can be lost. A 2008 study of 419 medical students showed that women had twice the empathy scores of men and that scores declined at the end of the third year, when students had begun regular exposure to patients during clinical rotations — exactly at the point where they needed more not less empathy. The 2008 study is not the only one showing this decline, but the trend can be prevented: A study of 209 students at the Robert Wood Johnson Medical School found that empathy was maintained among third-year students who received specialized training.
Looking at bleary-eyed students in front of me, some of whom had their textbooks open trying to prepare for an upcoming exam while I talked, I could see why the grind of medical training could lead to an empathy problem: stress, anxiety, competitiveness and sheer lack of time.
Standing at the podium, I asked the students: “Do you need to show compassion, or do you need to have compassion?”
No one volunteered an answer. I had put forth the same question to my father, who had had bypass surgery and is a cancer survivor. He said, “You can’t be compassionate with every patient. You will get burned out.”
I could see what he meant. In a day’s hospital rounds, I see two or three patients who are terminal. With respect and politeness, I explain the condition in simple language to them and their families, but then I carry on. I hope another specialist or their primary-care doctor will spend more time with each of these patients.
A good technique for showing compassion, I told the students, is simple: 3 T’s. Talk or listen, take time and touch. Merely taking the time to talk and listen to patients is comforting, as is a doctor’s touch.
I shared with them what Branch had told me: “You have to be genuine; otherwise it will show.”
In my practice, I find that each patient is different in his or her need for compassion. The art of medicine is not just choosing the right medicine but gauging the needs and providing reassurance and comfort to the patient. A burly man might appreciate a pat on the shoulder while an elderly woman might like me to hold her hand during a conversation.
Recently I have tried different strategies to humanize my interaction with patients. I ask them what kind of work they do, where they grew up and whom they live with. A medical school mentor of mine sat on the edge of the patient’s bed. With so much concern for drug-resistant bacteria in the hospital today, I tend to keep a little more distance, pulling a chair up to the patient’s bedside.
At the end of my lecture, a student sitting in the back row asked, “Did you confront the doctor who spoke to your patient rudely?”
I felt my face flush. “No. But I did apologize on behalf of the doctor.” I am not alone in looking the other way. A 1999 study found that most doctors were reluctant to respond to perceived disrespect, uncaring attitude or hostility toward patients by members of their medical team.
Likewise, few patients confront doctors about their behavior. So the burden of self-reflection on issues of compassion often remains with the doctors themselves or a training program such as the one designed by Branch.
I believe that doctors and other health-care providers are genuinely compassionate and that this is often what steered them toward medicine in the first place. But with uncertainties in health care, increased workload and limited time, for many the joy in the work is lost, and this comes across in doctor-patient interactions.
On my initial visit, as I considered what to do to show compassion to Mr. Venata, I surveyed my surroundings. I reached for a clean towel and gently wiped the sweat off his brow and offered him some ice water, a task usually relegated to a nursing assistant. A few weeks later he left the hospital to begin hospice care.
I am not sure if my simple act helped counterbalance the thoughtlessness of his other doctor. But the incident certainly was a reminder to me of the kind of physician I want to be.
Jain is an infectious-disease specialist in Memphis and an adjunct assistant professor at the Rollins School of Public Health at Emory University in Atlanta.