Humanising healthcare
BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6262 (Published 13 December 2016) Cite this as: BMJ 2016;355:i6262
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Youngson and Blennerhassett contrast our universal need for kindness and compassion when we are sick, injured or facing a life crisis, with our own professional behaviour, that they suggest is sometimes very different. “ Too often, what patients receive is rushed, clinical and detached health care.”
In NHS primary care, where ten minute consultations are the norm, and mental health issues loom large, the authors’ fears are likely to be very real.
Visit a dentist with toothache, and you might occasionally have an summary extraction, emerging twenty minutes later; problem solved.
More likely, you will be told the problem requires more time, perhaps half an hour for a filling. Maybe a few visits, and hours, if a root filling and crown are needed.
Once the nature of the problem is clear to the dentist, he or she can plan, and explain the necessary treatment.
Visit a GP with heartache, gloom or anxiety, and after ten minutes partly taken up with completing a depression questionnaire, you may well emerge with a prescription for a psychotropic.
The fact that your mood disturbance may date from distant antecedents, unresolved grief, recent trauma, or many other causes, will remain unexplored by you and your GP. Not that it makes much difference, when SSRIs, their accuracy and sophistication, are the modern medical equivalent of an antique blunderbuss.
“ Compassion is not so much about being kind, it is about being creative, to wake a person up.” (1)
Michael Balint explained that a GP who knows a patient well, over many years and during the life experiences common to us all, is in no way inferior to a pschoanalyst . Both become equally informed, but both need experience and intuition to move forward. (2)
Continuity of care is a lost cause in many modern practices, and GPs may need to follow Balint’s other advice, setting aside longer sessions to listen to, and understand a patient’s narrative.
Impossible to find the time ?
But possible to justify the continuing acceptance of quick fix scripts for psychotropics, when the the ‘effectiveness’ and safety of those drugs has been so comprehensively exposed by Peter Gotzsche ? (3)
Perhaps the RCGP should consider making Gotzsche’s book an obligatory read for it’s exam candidates, and also suggest that GP practices return to a more sensitive era, when the need for some patients to have longer appointments was understood.
Dentists manage it.
1 Trungpa Rinchope. Cutting through Spiritual Materialism. Shambala. 1973.
2 Michael and Enid Balint . Psychotherapeutic Techniques in Medicine . Tavistock, 1961.
3 Peter C Gotzsche. Deadly Psychiatry and Organised Denial. Peoples’ Press. 2015
Competing interests: No competing interests
I agree with the thesis expressed by R. Youngson and M. Blennerhassett in their Editorial (1) that inhumanity which people often experience when they run into healthcare system is rooted in disvalues widespread in the society. Hence, authors conclude, health workers should become advocates for a compassionate society in order to humanise healthcare.
But: where is compassion rooted? The Editorial mentions two grounds where this good plant can grow: the common ethical values of humankind, as they have been interpreted by the World Medical Association in the Declaration of Geneva, and religious faiths, which share compassion itself as their “golden rule”.
Both these paths can effectively lead to the same goal. The non-religious Italian poet Giacomo Leopardi, who faced disease and disability throughout his short life, asserted that solidarity is the only defence humans can deploy against Nature, which he felt as fascinating, but hostile (2). Social competition, one of the key elements antagonizing healing processes according to Youngson and Blennerhassett (1), is marked as foolish by Leopardi, such as allied forces were fighting each other instead of dealing with their common enemy (2). Back to the first century, Lucius Annaeus Seneca looked at both free people and slaves as conservi (co-slaves) of the adverse fate (3).
Indeed, human solidarity, which from a Christian point of view should not be interpreted “against heaven”, but on the contrary as fraternity in one common Father (4), is not just the root of compassion. It paves the way to reciprocal benevolence. In fact, if I am “empty” of my prejudices and even of my diagnostic pre-reasoning in front of my patient, I promote a better communication of symptoms and circumstances, which in its turn leads to more accurate diagnosis, more appropriate treatment choice and improved adherence (5). More in depth, if I go so far as to “empty” myself, I let the patient enter in me. This way, I put the basis for a true relationship, which can be “therapeutic” for both the patient and myself, because human connexions give meaning to life (6).
In my experience, building therapeutic relationships requires not only putting at a side diagnostic reasoning, but even postponing personal concerns and whatever can occupy my mind, when I listen to a patient. But this is a general rule of life, which has the potential to build meaningful connexions not only with patients, but also with colleagues, other health professionals and whomever we meet. When we empty ourselves in front of others, this is perceived as love, of course when it is accompanied by concrete actions. Hence, it promotes a response of solidarity not limited to ourselves, but directed around: it can stimulate, or even reawaken, the aptitude to love. And this builds knots of solidarity which can give life to the society around us (7). It is what we celebrate at Christmas. It is the root of a compassionate society. It is the root, for us as physicians, of a relationship-based medicine.
REFERENCES
1. Youngson R., Blennerhassett M. Humanising healthcare. We have to start by building a more compassionate society. BMJ 2016; 355: i6262. doi: 10.1136/bmj.i6262 (Published 13 December 2016)
2. Leopardi G. La Ginestra, in: Giacomo Leopardi, Canti, Penguin Classics, London 2010
3. L. A. Seneca. Epistulae ad Lucilium. Ep. 47, 1
4. Gospel by Matthew 6, 5-15
5. T. Greenhalgh e B. Hurwitz (eds). Narrative Based Medicine, BMJ Books, London 1998
6. Larson EB, Yao X. Clinical empathy as emotional labor in the patient-physician relationship. JAMA 2005; 1100-1106
7. Lubich C. Unity. New City Press, Welwin Garden City 2015
Competing interests: No competing interests
This editorial is not only relative to physicians, but all healthcare providers, NPs included. So many of us are struggling with compassion fatigue and burnout. I see new nurses and NPs along with new physicians coming into the work force who within a few years are questioning their choice of profession due to feelings of burnout, frustration and cynicism . I think all healthcare fields need to start focusing on healthcare guidelines for the whole person, not just disease management. Great editorial and would love to see more scholarly articles on this topic.
Competing interests: No competing interests
Thanks to Mongjam Meghachandra and Reeta Devi Singh for their eloquent description of the art of medicine and the healing power of listening. I agree whole-heartedly. The limitations of space in the editorial didn't allow me to share all the references I wanted to include. Stewart [1] showed in primary care consultations that when care is patient-centred and the doctor and patient find common ground, the number of patients requiring further tests is reduced six-fold and the number of specialist referrals is more than halved. These patients also recovered better from their illness. Bertakis [2] showed that when patients receive less than the median amount of patient-centred care in primary care, the total annual cost of their healthcare was 50% higher than patient who received above the median patient-centred care.
Thus, when we slow down and start really listening to the patient, it eliminates a great deal of downstream work, makes our day less busy, and the medicine more effective. In an overloaded service, slowing down is a challenge. Even in my first-world nation of New Zealand we have doctors in poor communities seeing 60-70 patients a day. One such doctor told me an inspiring story of how she transformed her practice and eliminated her stress by giving the gift of time to her patients: http://heartsinhealthcare.com/the-feeling-that-i-have-to-fix-something-f...
Thanks again for your response.
References
1. Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, et al. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49(9):796-804.
2. Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med. 2011;24(3):229-39
Competing interests: No competing interests
This is an important reminder for every healthcare clinician and leader who might be reluctant to cross the well established barriers of how things are traditionally done in medicine. When designing a system, it is imperative that you understand the needs of the people you are designing the system for. Typically tasks, technology, and tools are focused on 'how to', with little discussion about 'what' or 'why'. The people whose needs are served most directly by tools that are efficient, timely, responsive, accurate and productive are the ones who are buying and paying for those tools. But, the same values may not be priorities for all stakeholders. To succeed, healthcare systems need to meet the needs of patients, of clinicians, of leaders, and of payers. All are interdependent - clinical, financial, operational, and personal. To be truly "Patient Centered", those less easily measured, subjective, all too messy human needs of vulnerable patients and their families must also be a priority.
There is a plethora of research demonstrating the clinical, financial, organizational and personal benefits of relationship building across all levels of the healthcare system. Although so many already know this, little significant system wide change has been made and maintained. Every system of every kind is geared to seek equilibrium. That means that if change in any part of the system is to survive, the entire system has to change to accommodate it. No change is sustainable without that happening. Newton's mechanistic determinism was long ago proven to be an incomplete theory. But it is the one that medicine (and so much else) clings to. Financial, clinical, and patient needs, when addressed separately, can lead to conflicting priorities. If we are to meet our interdependent needs in a sustainable way across the entire system, we have to widen our thinking from individual 'silos' to systems. That's what Einstein meant when he said "You can’t solve a problem with the same thinking that crated it".
Competing interests: No competing interests
With the advent of newer technologies and equipments the health care sector is witnessing rapid changes in patient care. The age old clinical methods has lost steam in the diagnosis, being replaced by scans and laboratory tests. Thus, the need for detail enquiry about the health problem is also declining. Doctors and paramedics, nurses are merely acting like human machines fitted with standard operating protocols. It has been often said by veteran physicians that talking, careful listening and counselling relieves 50% of the problem of the patients who feels that there is hope and light at the end of the conversation. This fact is often neglected in modern day practice of medicine. Holding the hand and simple kind words of the doctor or the nurse makes the patient elated and helps in the healing process. This positive approach is a must for all the health care providers.
However, the rush of patients, limitations in time to talk to the patients and heavy work schedule, paperwork, legal problems etc. has been the major obstacles in performing a humane approach to patient care. After history taking and examination, only a battery of laboratory tests are ordered and till then only presumptive treatment is given. The worries of the patient are unheard of and after the tests reports only the doctors or nurses come and talk about medicine and some do's and don'ts. There is no ear to the queries of the patients who are impatient about their condition. How these can be meted out. It is not possible when a physician has to see about 200-250 patients in the outpatient departments of hospitals in a span of about 240 minutes: about a minute for a patient ! It is impossible. Let the Governments look into this aspect in the developing countries and increase the health care providers and fix a certain number of patients each day. This only can help in bringing about a humanising approach to health care.
Competing interests: No competing interests
Hi
Thank you for this article. My mother was in long term care for nine years before she died. She always received good clinical care but next to no human connection. The care workers were too rushed, had too much paperwork and were too under-staffed to see each resident as individuals in need of, say, hugs or attention, nor were such activities encouraged. This bothered me a lot. One time the institute's director said to me directly, "We're all just covering our health care asses." Dear Gawd!
Competing interests: No competing interests
The practice of Medicine with its daily professionalism is both science and art. The art of medicine is intrinsic to the humanistic fibre of medicine. It involves compassion, care, competence, hope and above all the “human touch.”
Fragmentation, super specialties and the slow disappearance of the family physician have taken the away the most humanistic approach to medicine, with gadgets and technology ruling healthcare. It is therefore nice to reminisce during times of Xmas Eve with Santa Claus’s love of humanity how well physicians incorporate humanity in their science of medicine.
As William Osler has stated “Medicine is a science of uncertainty and art of probability.” Medicine needs to treat more of the human being than only the physical ailments.
Competing interests: No competing interests
Re: Humanising healthcare
Impact of behavioral science curriculum in medical education
Background:
Humanization of health care is defined as a state of well-being, involving affection, dedication, respect for the other, that is, to consider the person as a complete and complex being (1). We applauded this insightful editorial and sincerely appreciated author’s call for building a more compassionate society (2). When we are sick, injured, or facing an existential life crisis, our greatest human need is loving kindness and compassion in response to our vulnerability and suffering (2).
Most commonly young generation medical graduates find it difficult to initiate respectful and compassionate dialogues with their patients while working in a crowded out-patient department. Many of them fail to maintain professional conduct in a stressful working environment. Some of them often feel sick due to burn out state of their mind after long hours of emergency ward duties.
It is most unfortunate that many of them did not get an opportunity to learn about behavioral science as a part of their curriculum during their medical school training program. They were never been exposed to the local community for a supervised health screening program with a mission to develop doctor-patient relationship and professional communication skills in real life scenario. Psychological state of our patients vary widely. Many of our patients expect kind and friendly approach before explaining their personal health problems.
In recent years behavioral science has created its own space in medical curriculum which is now taking care of building foundation of compassionate behavioral changes among new generation of medical professionals. Patient-centered care has been a focus of health care management for many years, with emphasis ranging from the policy and health system levels to individual care at the bedside.(3) We suggest that work environments that support caring and compassion, for patients as well as for care providers, best provide a foundation upon which high quality patient-centered care can flourish (2). One of the challenges that makes humanizing health care difficult is the lack of financial resources for improving the physical and material structure of the services (3). It is necessary to understand the patient as unique and irreplaceable, who deserves to be treated with dignity (4, 5).
In recent years, the outreach program of All American Institute of Medical Sciences, Jamaica is gaining popularity and our medical students are getting early exposure to local population and their cultural background, which may help them to understand the human need of loving kindness and compassion in response to their vulnerability and sufferings.
Concluding remark:
The routine class room teaching of doctor-patient-relationship and case history taking course work, remain incomplete till we expose our young medical students to interact in a real life scenario. Medical professionals need a supervised environment to develop compassionate relationship with unknown patients in a limited time period. A supervised and well-designed training course work on behavioral science may help to build up confidence and self-respect among young generation medical students. All patients want to be looked after by a good doctor. This is because they know instinctively that a doctor's decisions and advice about diagnosis and treatment can affect the outcome and possible consequences of illness and may make the difference between life and death (6)
Nothing tests our communication skills so much as breaking bad news. Such conversations can be extremely emotional for both doctor and patient. The right words said in the right way make a huge difference (7). Compassionate behavioral skills of medical practitioners often help to reduce anxiety and worries of patients and accompanying relatives.
We understand that behavioral science curricula may even include content that favors the students' humane education, however, curricula hinder such content being effectively appropriated by the students in a significant manner, which includes the possibility of the content being transformed in routine care actions. More integrative models, and especially those that permit students to gradually approximate content to professional practice, connecting it to theoretical references, may have a greater potential for improving critical-reflective learning committed to reality (1).
References:
1. Rev. esc. enferm. USP vol.46 no.1 São Paulo Feb. 2012 http://dx.doi.org/10.1590/S0080-62342012000100029
CRITICAL REVIEW: The humanization of care in the education of health professionals in undergraduate courses*
2. Editorials: Christmas 2016; Humanizing healthcare: BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6262 (Published 13 December 2016) Cite this as: BMJ 2016;355:i6262.
3. Re-humanizing Health Care: Facilitating “Caring” for Patient-centered Care
Cheryl Rathert, Timothy J. Vogus, and Laura McClelland
The Oxford Handbook of Health Care Management
Edited by Ewan Ferlie, Kathleen Montgomery, and Anne Reff Pedersen
http://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780198705109.001.0...
4. Rev Saude Publica. 2013 Dec; 47(6): 1186–1200. doi: 10.1590/S0034-8910.2013047004581: PMCID: PMC4206092 : Humanization policy in primary health care: a systematic review: Carlise Rigon Dalla NoraI and José Roque JungesII
5. Humanizing Health Care: Creating Cultures of Compassion With Nonviolent Communication (Nonviolent Communication Guides) Paperback – October 15, 2010: by Melanie Sears RN (Author)https://www.amazon.com/Humanizing-Health-Care-Compassion-Communication/d...
6. Education And Debate: GMC and the future of revalidation: Patients, professionalism, and revalidation: BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7502.1265 (Published 26 May 2005); Cite this as: BMJ 2005;330:1265
7. Breaking bad news: BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7500.1131 (Published 12 May 2005) Cite this as: BMJ 2005;330: 1131.
Competing interests: 1. The author is teaching Behavioral Science in different USMLE based medical schools since 2006. 2. The outreach community health screening program was organized under All American Institute of Medical Sciences in Jamaica on 17th March 2017.