Pathways to Compassionate Care

"It is easier to act your way into a new way of thinking than it is to think your way into a new way of acting."

This aphorism, noted by UCSF physician Christopher Moriates in his insightful essay "A Few Good Words," serves to justify one approach to improving healthcare communication.  The idea, he admits, seems too simple to be important - that we change a small behavior as a first step to opening ourselves up to our patients, and to creating greater connection.  Specifically, he recommends that we simply stop asking patients "Do you have any questions," and ask, instead, "What questions do you have?"

The use of open-ended questions like this is just one of a whole toolset of "micro-skills" that are shared as part of our day-long Relationship-centered Communication (R.C.C.) course, designed specifically for Northwell physicians in collaboration with the Academy for Communication in Healthcare.

The curriculum is predicated on several assumptions.  One is that while attitudes influence our behavior, the converse - that deliberate actions shape attitudes - is also true.  A second is that we feel empathy for our patients more often than we express it.  It follows logically that patients are deprived of the emotional benefits of feeling cared about whenever their physician is experiencing - but not communicating - this state of mind called empathy.  (In Buddhist thought, the same state is described as "compassion."  More on that shortly.)  The prescription brought to learners in the RCC curriculum addresses this gap with specific empathic behaviors - described by terms like reflection, legitimation and exploration - that physicians can adopt in their day-to-day practice.

Legitimation, for example, is a technique whereby the physician "legitimizes" the patient's emotional relationship to his problem - "I understand.  Most people with chest pain like that would be afraid..."

Yet a third assumption is that there is a need for physicians to create "relationship" and communicate caring irrespective of how we actually feel about the patient. Most seasoned practitioners admit that we don't always feel real connection with our patients.  This is human nature. At such times, professionalism dictates that we "fake it."  Some people might object to what seems like dishonesty, but when burdened by fatigue or challenged by a patient's hostility, oppositionality or lack of gratitude, sometimes we recognize the need to shoulder on, relying on sound habits of bedside interaction that are serviceable irrespective of whether there is authentic empathy for that patient in that moment.  It is not, after all, our duty to like every person we treat, but it is most definitely our obligation to treat every patient with courtesy, respect and diligence.

I've just read Medicine and Compassion, the co-production of David Shlim and Chokyi Nyima Rinpoche, a physician and an Buddhist monk, and I'm afraid the authors of this wonderful book would disagree with any defense of well-intentioned artifice.  Their view, in short, is that we can't really fake it.  When one considers the philosophical foundations of Buddhism, this conclusion comes as no surprise.  In their world view, thoughts and emotions create real effects in the real world.  The authors note:

"A benevolent frame of mind can ease the suffering of other beings, and a malevolent frame of mind can cause immense suffering."  

How one achieves this "benevolent frame of mind" --  which is also called "compassion" or "loving-kindness" --  is a much longer story.  It is a story worth pursuing, however.  In walking the path of meditation, in seeking to understand our connectedness, in pursuing "enlightenment,"  there are benefits for our own happiness as well as for our capacity to be present to our patients.  It is this attentiveness that our patients may need most as they confront the forms of suffering that are so familiar in the kingdom of the sick.