This year, President Obama and Congress will attempt health care reform, giving particular attention to the issues of affordability, quality, and access to care. Another area that I have been concerned about—one that is certainly linked to quality—is compassionate care.
Let me share an example: A few weeks ago, while assisting my granddaughter in putting a bed frame together, my wife fell and struck her face on an end table. We took her directly to the local emergency center. After about an hour, she was ushered into the exam room, where the physician, without ever actually speaking to her, made a quick examination and dictated orders for CT of the head and face to the nurse. He said the PA would be in to suture up my wife’s lacerations. He showed about as much compassion to her plight as the end table did.
Now, there is some good news in this story. After the CT scan (which was negative) and another three-hour wait, the PA entered the room. What a contrast! He was appropriately concerned and spoke directly to my wife while he examined her. He spoke to me to let me know what he recommended. He took an appropriate history, talked to my wife about safety at home, and also appropriately interjected some humor. His demeanor (and compassion) significantly calmed my wife (and me), and further distress from this otherwise frightful situation was averted.
Now, I am about to go out on a limb: How often have you heard stories about physicians showing a lack of compassion? I have heard such stories many times. In fairness, I have known many physicians who were very caring and compassionate. But unfortunately, in my experience, this has been the exception rather than the rule. Some say that medical school and residency tend to knock the compassion out of people.
Now, if I turn the question around and ask how often you’ve heard about PAs or NPs showing a lack of compassion, the answer changes. It is not uncommon to hear that the PA or NP went above and beyond and was very compassionate in taking care of patients. This seems to be the rule rather than the exception. (OK, I admit that I am biased.) The question “Are PAs and NPs more or less compassionate than physicians?” would be the basis of a great study. My editorial comments are purely anecdotal and may inadvertently perpetuate a myth.
From the time of the Flexner report,1 medical educators have been criticized by foundations, educational institutions, and professional task forces for emphasizing scientific knowledge over many other skills, including compassion. When it comes to compassion, will we know it when we see it? It is true that there is no shortage of books and articles on the subject of compassion; however, there is little consistency. According to Purtilo,2 “There are three powerful components of compassion: (1) The character trait or virtue of sympathetic understanding recognized as a virtue, (2) Willingness to carry out your professional responsibilities toward the patient, recognized as moral duty, and (3) Readiness to go beyond the call of duty.” The word compassion comes from the Latin passio (“suffering”) and con (“with”), a concept that encourages the desire to treat others with sympathy and understanding.
As we evaluate health care reform this year, we must revisit how best to assess and promote compassion. It is clear to me that an effective method must be multifaceted. The success of any clinician is based in part on professional and interpersonal skills—including compassion—developed before, during, and after the process of formal education. Some would argue that compassion cannot be taught: Either it’s there or it’s not.
I am calling on all educational programs to reevaluate their selection process and to give greater attention to professionalism, particularly as it relates to compassion. Recognizing that current interviewing processes are not suited to evaluate an applicant’s professionalism, I suggest they be redesigned to have applicants write reflective papers examining ethical situations. Alternatively, applicants might be required to participate in group problem-solving exercises during the interview process.
A crucial aspect of any professional educational curriculum is the development or enhancement of professional behaviors and role identity. There is evidence that unprofessional behavior exhibited during the educational process is a predictor of future problems with regulatory boards. Both subjective and objective measures should occur during the educational process to assess compassion. Some of the best ways to assess this component of professionalism are through faculty and preceptor modeling, strong professional expectations, reflective papers, peer evaluations, standardized patients, and objective structured clinical examinations.
There are some objective assessment tools that look at emotional and cognitive intelligence; however, they are expensive and require certified evaluators. Assessing actual student attitudes and behavior during the educational process is arguably a better way of ensuring that graduates are competent in these areas. Judgments about attitudinal and behavioral competencies are legitimate and no more arbitrary than those made about scientific or clinical knowledge. Therefore, teachers and mentors must demand appropriate behaviors when they interact with students in clinical teaching environments.
According to Punkett,3 “If ethical, professional, and interpersonal skills are important to the profession and should be taught in professional programs, then students need structured feedback on these behaviors, just as they receive feedback on their medical knowledge and clinical skills.” Institutions can begin (or enhance) development of these skills by publishing standards that address professional behaviors in addition to the academic and technical standards that are the mainstay of curricula.
We cannot overestimate the importance of modeling and the role that peers and preceptors play in the process of fostering compassion in clinicians. According to Cooke et al,4 “Cognitive psychology has demonstrated that facts and concepts are best recalled and put into service when they are taught, practiced, and assessed in the context in which they will be used.”
PAs, NPs, and physicians are expected by our society to meet the highest professional and ethical standards. I started this editorial by illustrating where one physician did not meet this standard and where one PA did. The title is a little misleading (purposefully), since I think we (PAs and NPs) are leading the way in compassionate health care. We must continue that leadership and model that behavior to our peers and colleagues who are physicians and avert the demise of compassion in our health care system.
I would love to hear your examples of situations when one of your peers met and actually exceeded your expectations of compassionate health care. Please send your responses to this editorial to PAeditor@qhc.com.
1. Flexner A. Medical Education in the United States and Canada. New York, NY: Carnegie Foundation for the Advancement of Teaching; 1910
2. Purtilo RB, Criss MI. Ethical Dimensions in the Health Professions. 4th ed. Elsevier Science; 2005:267.
3. Punkett MJ. Professionalism in physician assistant students. Perspect Physician Assistant Education. 2002;13(1):54-56.
4. Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner report. N Engl J Med. 2006;355(13):1339-1344.