Lucy Brennan

Published in JHH12.2 – Works that reconnect

I am a third year graduate medical student at Brighton and Sussex Medical School. Alongside a traditional scientific academic background, I have also enjoyed courses in English literature and theatre arts with contemporary dance. Pursuing interests within the humanities has, I believe, complemented my medical training by helping to develop an empathetic and compassionate approach to patients and their care. My time as a research assistant at the Institute of Child Health and Great Ormond Street Hospital has additionally contributed to this. I have an interest in paediatrics and I have been fortunate to be involved in several paediatric research projects, including an expedition to Everest Base Camp in Nepal for high altitude studies. I’m very much looking forward to my clinical elective at the Red Cross Memorial Children’s Hospital in South Africa this summer.

This year students were asked for an essay based on one of the words from the BHMA ‘holistic thesaurus’. This is a collection of 11 words describing the holistic approach to healthcare:

connected compassionate self-caring intuitive integrated empowered resilient balanced diverse meaningful community-minded

Together they encompass the qualities needed to become a holistic practi[1]tioner. We were looking for stories that illustrate one of these themes via the student’s personal or professional life.

For the second year running the judges gave the first prize jointly, to Lucy Brennan and Eleanor Tanner. Both chose to write about compassion. Lucy’s essay is printed in this issue and Eleanor’s will appear in the next issue.

Medical students often feel useless at the start of clinical training in their third year. They feel they cannot contribute meaningfully as they do not yet have the adequate knowledge or skills. Is there a way we as students can turn this around? Is there a special role we can play to utilise what we have learnt in the first two years of the curriculum? We might not know how to cannulate a vein well, interpret ECGs properly, formulate accurate differential diagnoses or management plans, but that will come in time. However we can draw on our innate compassion and develop it throughout our training and thus contribute meaningfully now.

Compassion refers to a deep awareness of the suffering of another coupled with the wish to relieve it (Spiro 1992). Compassion responds to feelings that are evoked by contact with the patient; those feelings shape our approach to care. Compassion can be practised as a student by taking notice of what is happening on ward rounds, reflecting upon it and thinking what we can do to make the situation for the patient better. For example imagining how a patient is feeling when they are being ignored while the team talk about them without including them in the conversation. Compassion means to be interested in the patient; their personal lives, their family, and how their illness is making them feel. Compassion means respecting and valuing a patients’ dignity, for example when an examination is being carried out without the curtains being drawn. Students do have a vital role to play and are in a privileged position that if used appropriately can make a difference to care. Students could ultimately lead the way with cultivating compassion in the NHS. I have found that as a student observing on the wards we are also able to recognise that sometimes there is a hidden agenda with what is really troubling the patient and not just their presenting complaint. By demonstrating compassionate qualities students could be the gatekeepers to understanding that hidden agenda, what the patient really wants to tell the doctor but doesn’t know how to.

Humanity and compassion

‘One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.’2

(Peabody 1927)

One of the main benefits we as students have is time. Time to listen, time to reflect, time to ask questions and time to be compassionate. I have been struck by one particular case in the hospital that highlighted to me the positive difference compassion can make. Miss M was a 55-year-old female admitted to the ward with a severely distended abdomen related to a chronic history of alcohol use. She had several procedures to drain the fluid from her peritoneal cavity. Essentially, she was in liver failure. I had been part of the gastroenterology ward rounds and thus I had met Miss M on a couple of occasions. One issue the team wanted to resolve was reducing Miss M’s dose of diazepam. They didn’t understand why she was on such a large dose and thought it best for her medical management to reduce it considerably. Miss M was clearly anxious about this and told the team she was worried about reducing it because she takes it for her ‘nerves’. The team was fairly dismissive but as a student watching the ward round I could see the anguish in her face. Later on that afternoon, I went back to Miss M to talk to her. What began as a generic history-taking exercise unravelled into a very honest and emotional discussion. Miss M informed me that the reason she was on such a high dose of diazepam was due to her extensive psychiatric history of depression and suicide, including an inpatient stay at a psychiatric hospital. I had never heard this spoken about on ward rounds. She told me she was anxious about reducing the dose for fear of triggering another episode.

I believe the reason Miss M opened up to me as a medical student was because I had the time to sit down next to her and listen. She was given space and time to talk. I brought her the cup of coffee she had been asking for. I tried to be sympathetic and non-judgemental when she spoke about her drinking. When she told me she was anxious about symptoms re-occuring I openly asked her whether she was feeling depressed now and whether she had been having any suicidal thoughts while at the hospital. To my surprise her answer was yes, and she even detailed that she had thought about the way she would commit suicide, although she would not act upon it. We continued discussing in an informal way her concerns and past psychiatric management and what she wanted to happen in terms of getting support. I went back to her FY1 [foundation] doctor in the team and explained Miss M’s concerns over the diazepam and future support. The FY1 was completely surprised by this as he had no clue about her past psychiatric history – he had not looked back far enough in the notes – he was only focused upon the gastroenterology-related condition she presented with.

The key learning points I took from this case are:

• taking notice of patient-initiated clues
• involving the patient in the management of their condition and unravelling hidden agendas
• compassionate communication to allow the patient to talk openly and build a trusting rapport.

Taking notice of patient-initiated clues

The doctor is in a position that acts as a ‘specialist witness’ of the illness experience – thus should manage care in the patient’s best interests, particularly when the patient finds it difficult to communicate. Levinson et al (2000) state that 76% of patient-initiated clues in primary care are emotional in nature; with 80% of these related to psychological or social concerns in the patient’s lives. Surprisingly, only 21% of these clues were interpreted by clinicians, showing a great deficit of missed opportunities to adequately acknowledge patients’ feelings. I believe it is vitally important to acknowledge patient clues, even in the context of a busy clinical practice or on busy ward rounds, because this study showed that visits with missed clues tended to be longer than visits with a positive response, highlighting the benefit to both patient and clinician. As in the case with Miss M, acknowledging unspoken patient clues and acting upon them can provide a wealth of important information that was previously not encountered.

Involving the patient in the management of their condition and unravelling hidden agendas

According to Stephenson (2004) effective decision-making can be achieved if the doctor discovers what the patient thinks or fears about the situation, and what the patient expects – ie the patient agenda. Patients generally feel much better when they are actively involved in discussions about their treatment. They are more likely to adhere to the treatment, even though it may be unpleasant (Delbanco et al 2001). Studies revealed that quality of care and collaborative decision-making is becoming increasingly important in the field of chronic diseases (Frosch and Elwyn 2011, Hirsch and Simpson 2013, Van der Eijk et al 2012). ‘Patient centredness’ is a key element of quality of care and a study by Van der Eijk et al (2011) explored the experiences of patients with chronic disease. Results highlighted that patients desired more emotional support and wanted more active involvement in clinical decision-making – but currently lacked sufficient information. Conclusions from the study represent a disease-specific model of patient-centredness that can be used as a vehicle for clinicians in implementing patientcentred care tailored to the preferences of each individual patient (Nijkrake et al 2009). Two additional studies by Van der Eijk et al (2013) and Grosset et al (2005) highlight further issues, including that patients with certain chronic diseases sometimes assume a passive role as they lack the tools to self-manage their condition (Van de Belt et al 2010). Delivering patient-centred care to patients with chronic disease can be complicated given the complexity of conditions that may have cognitive, emotional and motor problems (Coulter 1999). As a consequence of this, it could lead to regarding patients as carriers of disease as opposed to people with a health problem (Shirky 2008). Miss M’s team were possibly too focused upon the liver condition that presented and failed to understand what the patient desired in the decisionmaking over her management.

Compassionate communication to allow the patient to talk openly and build a trusting rapport

Healthcare workers arrive at compassion in their practice through differing experiences and at different times. It can emerge with life experience, clinical practice, and the appreciation that each of us is vulnerable in the face of ageing, health and life’s challenges. Compassion may develop over time, and it may also be cultivated by exposure to the fields of humanities, social sciences and the arts. These disciplines offer insight into the human psyche and the emotions expressed when confronting illness. One report (Shapiro et al 2004) has suggested that students should be encouraged to watch films that inspire compassion to make them more sympathetic, altruistic, and understanding. I would agree that broadening the curriculum to include humanities and the arts could help to cultivate compassion in their practice. Although the process of arriving at compassion can be challenging and multifactorial, showing compassion often occurs naturally and can be as simple as a gentle look or a reassuring touch that shows some recognition of the human stories and suffering that come with illness.

Time to stand and stare  

Although with such heavy demands and workload it is exceedingly difficult to take any time to ‘stand and stare’ but if we collectively as an NHS workforce take responsibility to stop and notice the small things that we each can do to make a difference to patients’ care then huge changes can be made. Making a difference as a student can be something as simple as helping a patient dial a family members’ telephone number or offering them a cup of tea. Time to stop and listen can expose key factors that will help manage the patients’ care, such as with Miss M. Arguably, what is equally as important as compassion to patients is also taking time to actively be compassionate to work colleagues. Every job role within the NHS is integral to its’ efficient running and every employee has their own particular stresses and responsibilities. I have learnt that as a student you can feel victimised and upset by the way some colleagues treat you but rather than reacting to this in a negative way we could empathise that they must be under a lot of strain, ie break the cycle of negative morale and promote a compassionate one instead. For instance, the consultant that is burnt out and aggressive to his students may just need somebody to smile and offer some help. Compassion towards patients and towards colleagues can be infectious and I believe students can be the pioneers to bring this about.

References

• Coulter A (1999) Paternalism or partnership? Patients have grown-up and there’s no going back. BMJ 18 pp 719–720
• Delbanco T, Berwick DM, Boufford JI, Edgman-Levitan S, Ollenschlager G, Plamping D (2001) Healthcare in a land called PeoplePower: nothing about me without me. Health Expect 4 pp 144–150.
• Frosch DL, Elwyn G (2011) I believe, therefore I do. J Gen Intern Med 26 pp 2–4.
• Grosset KA, Grosset DG (2005) Patient perceived involvement and satisfaction in Parkinson’s disease: Effect on therapy decisions and quality of life. Mov. Disord. 20 pp 616–619.
• Hirsch MA, Simpson AM (2013) Why bother with shared decisionmaking in Parkinson’s disease? Parkinsonism and Related Disod. 19 pp 928–929.
• Levinson W, Gorowara-Bhat R, Lamb J (2000) A study of patient clues and physician responses in primary care and surgical settings. JAMA 284 pp 1021–1027.
• Nijkrake MJ, Keus SH, Oostendorp RA, Overeem S, Mulleners W, Bloem BR (2009) Allied healthcare in Parkinson’s disease: referral, consultation, and professional expertise. Mov Disor. 24 pp 282–286.
• Peabody (1927) The care of the patient. JAMA 88 pp 876–82.
• Shapiro J, Rucker LM, Susan H, Campell TL (2004) The Don Quixote effect: why going to the movies can help develop empathy and altruism in medical students and residents. Families, Systems, and Health 22 pp 445–52.
• Shirky C (2008) Here comes everybody: the people of organizing without organizations. London: Allen Lane. Families, Systems, and Health 2004; 22; 445–52.
• Spiro H (1992) What is empathy and can it be taught? Ann Int Med 116 pp 843–6.
• Stephenson A (ed) (2004). A textbook of general practice. 2nd ed. London: Hodder Arnold.
• Van de Belt TH, Engelman LJ, Berben SA, Schoonhoven L (2010) Definition of Health 2.0 and Medicine 2.0: a systematic review. J Med Intern Res. 12 pp 18.
• Van der Eijk M, Faber MJ, Shamma SA, Munneke M, Bloem BR (2011) Moving towards patient centred healthcare for patients with Parkinson’s disease. Parkinsonism and Related Disorders 17 pp 360–364.
• Van der Eijk M, Faber MJ, Ummels I, Aarts JWM, Munneke M, Bloem BR (2012) Patient-centredness in PD care: development and validation of a patient experience questionnaire. Parkinsonism and Related Disorders 18 pp 1011–1016.
• Van der Eijk M, Nijhuis F, Faber MJ, Bloem BR (2013) Moving from physician-centred care towards patient centred care. Parkinsonism and Related Disorders. 19 pp923–927:
• 1016/j.parkreldis.2013.04.022. [Epub ahead of print].