Dr. Brian Hodges, Professor, University Health Network, University of Toronto
Tuesday April 18, 2017
Posted by Nadine Abdullah, MD, MEd, FRCPC
Could you imagine a simulation robot
providing you with impeccably perfect care, but without compassion? Or
compassionate but inefficient care from a real live health care provider without
the possibility to cure your disease or improve your health? Which is more
valuable to you? Care, or compassion? Is it necessary to compromise and choose
only one? What if you could have both?
In the age of expanding artificial
intelligence technology and deep learning systems, it is not so far-fetched to
ask these questions. The answers, we should contemplate before we re-imagine healthcare
to incorporate innovative technologies that could realistically replace human
beings, eliminating the human touch from healthcare delivery.
We were delighted to host Dr. Brian Hodges
for our Art of Medicine Lecture series to address the relevance of compassion
in healthcare. At the core of our relationships with patients, we are each
individuals with a basic human need for interactions based on emotion and
compassion. Patients feel more satisfied with compassionate care, and physicians derive more
satisfaction from their work when providing care with compassion.
At our most vulnerable, that need for compassion is magnified, not only as
patients seeking care, but as providers working in an environment where tragedy
and loss of life are witnessed not inside a vacuum, but with lasting impact in
all aspects of our lives.
If we take a step back from our work
environment, and reflect on our relationships within that complex and often-chaotic
environment, it is not hard to see that we have created an abnormal arrangement
between healthcare providers, and patients. Immersed in completing forms,
reviewing electronic charts for data, strapped to technological gadgets to
search for information, we barely speak to one another, let alone engage in
meaningful conversations with our patients.
How can we think of compassion, so it
maintains a primal role as we transform healthcare into an integrated system of
technologies? Dr. Hodges helped us envision compassion through a framework that
sees it as a behavior, a competence, a
value, and a resource.
Behaviour: One way to configure compassion is as a human and professional
behavior. Our behavior defines our compassion, or lack of it, as much as our
words. When we previously explored the early loss of empathy in medical
students in Dr. Catherine Yu’s talk “There’s
no Billing Code for Empathy – Graphic Narratives in Medical Education, February
9, 2017”, we touched on the heavy weight of the hidden curriculum and its
role in modeling undesirable behaviours, and reinforcing lack of compassion in
favor of efficiency in care. Artificial intelligence will be able to take over
cognitive tasks for diagnosis and treatment. The technology is there already,
ready and waiting to be integrated into our system. The possibilities to
maximize efficiencies in our system are endless. But we know the push to
efficiency is one of the greatest facilitators of compassion loss in trainees.
So we have important choices to make now. How do we use the time and space
gained from efficient systems? The benefit of automated processes moving us
away from time-consuming tasks and toward more patient contact time is
appealing. Can we seize and utilize it to return to the core of compassionate
care?
Competence: A deliberate artifact of our training is how our assessments drive
learned behaviours, such as taking an accurate history, or performing the steps
for a physical exam maneuver. Do we add “compassion” to the checklist of
performed tasks on an OSCE station? Do we incorporate a narrative assessment of
our student’s compassion longitudinally over the training period to reinforce
its prime location in the development of professional identity? If we frame
compassion as a competence, we can explicitly shape compassion as an expected
professional component of care, placing it in the forefront of our curriculum
giving it equal weighting to knowledge and technical skills. Evidence
from advanced cancer patients shows that
patient's perception of compassion as a competence in health care learners is
evident, and that teaching methods including patient-centered
communication, self-reflection exercises, and compassionate role modeling can be used to nurture
compassion from an innate quality, to sustained practice.
Value: In our institution, we have a long tradition of recognizing, valuing
and rewarding compassion, I daresay more so than we do for performance exams
now that we have done away with grades in favour of pass/fail. The coveted
“Golden Stethoscope Award” awarded for “demonstrating a combination of academic
achievement as well as attributes of a humane and compassionate clinician” is,
in my mind, the most valuable recognition of professional development in our
students. In post-graduate medical education, a similar award, the Sopman Humanitarian
Award is dedicated by peers and teachers to trainees who “encourage
characteristics of humanity, compassion and understanding along with the
ability to communicate with patients and families.”
Resource: But why stop there if we value compassion. Compassion is a finite
resource that needs to be refueled. Burnout strips us of compassion, and is widely prevalent throughout all stages of practice. If we are
to sustain compassionate care throughout decades more of practice, as
technology emerges that may replace much of our care, should we not equally
recognize, value, and reward compassion in the very teachers who seek to
espouse it in their students? If we are to maintain the compassion that drove
us to the varied healthcare professions, we must attend to the moment in which
we are providing care, without distraction from the varied tasks that pose
physical, temporal, and emotional barriers between healthcare provider and
patient. We can do so by advocating to build system-wide processes that foster
individual resilience, rather than placing the onus on the individual health
care providers for their own wellness. This is key to maintaining the
resilience that human beings need to deliver compassionate care.
Moving forward, rather than debate the
benefits and perils of expanding technology in healthcare, I am challenged to re-frame
its creep, and instead take advantage of it. During Dr. Hodges talk, I was
reminded of my initial reaction to the nuisance of point-of-care ultrasound
that crept up at the bedside in the hands of my trainees. Rather than see it as
a cumbersome tool that hinders the human interaction, we can re-frame it as a
tool to connect, to lay hands on the patient, and use the images to demonstrate
to the patient what we are seeing together, what it means, and how we will
manage it. In this way, we can see the technology as a means by which to enhance
the therapeutic relationship, by owning the investigations and findings,
sharing information and decision-making, rather than clicking the test from a
menu in the computer and seeing the patient carted off to another department to
be treated by someone else.
Virtual visits, remote monitoring,
holograms – the stuff of Star Trek – have already begun making their way into
health care. Make no mistake; this was not a talk for the future, but for how
we can prepare now to shape the future to be, as patients and healthcare
providers want it to be, as these tools percolate through our healthcare
delivery systems. Before posting this, I listened to our President and CEO Dr.
Peter Pisters give a visionary talk at Medical Grand Rounds on “The Rapidly
Changing Health Care Landscape and the Opportunities Ahead”. It was eerily
reminiscent of the future Dr. Hodges predicted for us, and a reminder to urgently
capitalize on this era to reinforce that “without compassion, there is
no healthcare.”
Resources:
From Detached Concern to Empathy: Humanizing Medical Practice
Compassion training in healthcare: what are patients’ perspectives on training healthcare providers?
Without compassion, there is no healthcare
Bio – Brian Hodges, MD, PhD, FRCPC
Brian D. Hodges is Professor in the Faculty of
Medicine and at the Ontario Institute for Studies in Education at the
University of Toronto; the Richard and Elizabeth Currie Chair in Health
Professions Education Research at the Wilson Centre and Executive-Vice
President Education at the University Health Network (Toronto General, Toronto
Western, Princess Margaret, Toronto Rehab Hospitals and the Michener
Institute). He is a practising psychiatrist and teacher. His research focuses
on assessment, competence, compassion and the future of the health profession.
His work has been recognized with the Association of American Medical Colleges
Flexner Award (2015) and the Karolinska Institutet Prize for Research in
Medical Education (2016).
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