Paquita de Zulueta, GP; therapist/coach

Published in JHH17.1- Stories in medicine

I have worked for 35 years as a London-based GP and have a special interest in mental health, migrant health, clinical ethics and professional wellbeing and development. I am honorary senior clinical lecturer at Imperial College, a cognitive behavioural therapy (CBT) therapist, and a qualified coach and mentor. I am a Schwartz Round facilitator and member of the clinical ethics committee of Imperial College NHS Trust. I worked for three months as GP lead for the NHS Grenfell Outreach Team following the disaster in 2017 and for 10 years as clinical volunteer for Doctors of the World London Clinic.

Benefits include greater empathy and compassion for colleagues and patients, reduced isolation, enhanced peer support and improved teamwork Click To Tweet

Setting the scene

Healthcare in the UK is in crisis: doctors and nurses are experiencing very high levels of stress and burnout, with the attrition rate of junior doctors and nurses rising (GMC, 2019; Beech et al, 2019). The current coronavirus (COVID-19) pandemic is imposing further enormous strain on an already stretched NHS. Health professional burnout is global and not confined to Britain (Lemaire and Wallace, 2017; The Lancet, 2019). Authorities such as the General Medical Council (GMC), having recognised that the medical profession is under great stress, are now making welcome recommendations on how to support doctors. The GMC
document Caring for Doctors, Caring for Patients (West and Coia, 2019) acknowledges that prioritising clinician wellbeing leads to better care and improved patient experience. The Point of Care Foundation (POCF) in its document Behind Closed Doors (Cornwell and Fitzsimons, 2017) highlights the need for staff to feel positive and engaged with work and ‘that staff experience should be given equal priority with patient experience at all levels of the healthcare system’. There
is also evidence that enhanced staff wellbeing translates into improved patient outcomes (The Lancet, 2019).

The NHS has been ‘starved’ of funding for several years and this is causing increased stress to the healthcare system and for those working within it (The King’s Fund, 2019). Yet lack of money and resources, albeit important, is not the only problem: NHS workplaces are often found to be unconducive to staff and patient
wellbeing with unacceptable levels of bullying and undermining of healthcare professionals (West, 2020). Dysfunctional leadership, team conflict, and steep hierarchies have been identified as predisposing.

The industrialisation and fragmentation of healthcare

In the last decades medicine and healthcare in general has become more bureaucratised and industrialised with emphasis on efficiency and transactional goals (De Zulueta, 2013). Healthcare is increasingly ‘marketised’ and viewed as a commodity with clinicians as ‘providers’ and patients as ‘consumers’ or ‘customers’
(Henderson and Petersen, 2002). ‘Care’ is disaggregated into discrete, monetised and measurable processes. This trend is accelerated and inflated by the advent of ‘big data’, machine intelligence and more broadly artificial intelligence. We are now in the age of the digital – the algorithmic – way of life. This restores the biomedical disease-focused contextualised model with a vengeance – the focus is on accurate diagnosis (preferably with the use of algorithms) of a clearly defined condition and of finding a targeted treatment in the form of medication, surgery or manualised limited-session psychotherapy; all this to produce predictable and measurable outcomes. For diagnosis and treatment choice, the idea is for the machines to churn through huge amounts of information (data) and the clinicians to be left to do the relational work – the ‘soft stuff’ – listening, empathising. The problem with this approach is that it assumes that the art
of deciding which treatment (or non-treatment) would be appropriate for the individual patient, and which would entail attuning to their needs and values – is something separate from the intellectual scientific work of diagnosis and prognosis. This compartmentalisation is erroneous, for these processes are welded together in a dynamic, iterative whole arising from reflection in action (Schön, 1991) and dialogue in the context of a healing relationship (Emanuel and Emanuel, 1992). One cannot cleanly separate the art and science of medicine – they co-exist in an inseparable whole (Kleinman, 2008). In the digital age true reciprocity is threatened, although those who promote ‘chatbots’ will argue that this is not the case. Care in modern healthcare is often fragmented: a lack of
cohesive teams in hospitals and the loss of continuity of care in primary and secondary care provides few opportunities for building relationships between
caregivers and their patients (Jeffers and Baker, 2016; Sudhakar-Krishnan and Rudolf, 2007). Modern (or postmodern) healthcare has created barriers to the
development of trusting relationships and the erosion of compassionate care ((De Zulueta, 2013; Mannion, 2014).

So how are doctors and other healthcare professionals to work, within these fast-moving, task-intensive, depersonalised, fragmented and technocratic systems?
The evidence suggests not very well; in this cultural milieu many experience ‘moral distress’, burnout and avoidable suffering (Dzeng and Randall, 2018). I will now explore how Schwartz Rounds can mitigate harm and generate more positive, humane systems.

What are Schwartz Rounds?

Schwartz Rounds are named after Kenneth Schwartz, a lawyer and father diagnosed at the age of 40 with an aggressive, and ultimately fatal, lung cancer and who, before his death from the disease in 1995, founded the not-for-profit Schwartz Center for Compassionate Care. He describes the treatment that followed the diagnosis as an ordeal that was ‘punctuated by moments of exquisite compassion’. He describes how acts of kindness – ‘the simple human touch from my caregivers’ made ‘the unbearable bearable’ Schwartz recognised the emotional load that healthcare professionals had to carry and their need for support. He also recognised how difficult it was for caregivers to retain their humanity in a busy, emotionally laden organisation: ‘Looking back I realize that in a highvolume setting, the high-pressure atmosphere tends to stifle a caregiver’s inherent compassion and humanity’ (Schwartz, 1995).

The Schwartz Center is dedicated to supporting caregivers and healthcare leaders, to strengthen relationships between patients and caregivers and to bring ‘compassion into every healthcare experience’. Rounds provide opportunities for individuals to share lived experiences by telling authentic stories that reveal their vulnerability and suffering as well as acknowledging the pride and joy that their work can offer. Schwartz rounds were rolled out in the USA from 1997 onwards and are a feature of hundreds of healthcare institutions (around 400). They were introduced in the UK by The King’s Fund in partnership with the Point of Care Foundation (POCF) in 2009. At the time of writing, the POCF now supports more than 220 organisations in the UK to deliver Rounds. These occur
in hospital trusts, hospices, care homes, primary care centres, ambulance centres, and even in prisons and police settings.

Schwartz Rounds aim to enable compassionate care and staff wellbeing. They offer protected, confidential forums for shared reflection and support. Typically they are an hour long and are held monthly in the middle of the day with food and refreshments for attendees. Rounds are open to staff from all disciplines, including clinical and non-clinical. They come together and reflect on the social, ethical and emotional challenges they encounter in their work within a safe and supportive space. Superficially Rounds have the format of the hospital ‘Grand Rounds’ but diverge sharply in content and form. The emphasis is not on clinical details or on problem solving but on the emotional contours of ‘the case’. The format consists of a ‘panel’ of speakers – usually three to four individuals from
the same team, but from different disciplines and varying levels of seniority, talking about an experience which affected them at a deep level. For example, you may have a senior consultant, a junior doctor, a nurse, and a physiotherapist each giving their personal experience of caring for the same patient. Each story is of equal worth. The facilitator sets the ground rules and an explanation of how the Rounds work. Before the meeting the panellists meet up with trained facilitators (usually psychologists) who help them to hone their stories to around five minutes each, highlighting the key moments, the emotions and conflicts raised, and the lessons learnt. The panel members are not expected to justify what they did or did not do – in fact a key role of the facilitator(s) is to deflect and shield the panel from problem solving questions such ‘Did you think of doing X?’.

Topics vary – such as a patient’s unexpected or poorly managed death, a patient who refused treatment, ‘difficult’ relatives, miscommunications. A typical theme could be ‘A patient I will never forget’ or ‘When things go wrong’. After the panel members have shared their stories, the facilitator(s) open up the conversation to the audience asking them if the stories resonated with them, or if they have their own related stories and reflections that they wish to share. Towards the end, the facilitators will give the ‘last word’ to the panellists and then wrap up the session, offering a synthesis of the themes that have emerged. Numbers of participants vary and can be more than 100. They are asked to fill in standard evaluation sheets which are then processed and disseminated to the facilitators and panellists as well as to the Schwartz Round steering group.

Personal experience

My interest arose when I began my journey as an academic activist promoting compassionate care and leadership in healthcare by writing articles, running workshops and seminars and building connections (De Zulueta, 2013, 2016). I read about Schwartz Rounds and was intrigued. By invitation, I witnessed a round at the Royal Free Hospital, then a pioneer trust for Schwartz Rounds in the UK. There must have been around 100 people in the audience. Having been part of GP Balint groups as a young principal, I was sceptical that reflective sessions could ‘work’ with such a large number of participants (Balint groups typically are small and closeknit – also facilitated by a psychologist or therapist). To my surprise I sensed a powerful collective engagement and solidarity in the room. Everyone was listening attentively, not looking at their phones or falling asleep. The facilitator was highly skilled and conveyed warmth and wisdom,
ensuring that the panel and audience remained focused on the emotional, not the clinical issues. Later on (2015) I decided to join the Schwartz Round initiative at Imperial College NHS Trust to which I am affiliated as a senior clinical lecturer. My qualification and skills as a GP specialised in mental health, group teaching and facilitation were of value. I then trained as a Round facilitator to become part of the multidisciplinary team.

Over the years issues other than challenges in patient care have emerged, such as coping with racism and homophobia from patients as well as colleagues, or trying to balance home and work life. Cases and themes included ethical dilemmas in paediatrics, choosing a career, dignity in dementia care, death and dying on the wards, mental health crises, developing team bonds and ‘emotional labour’. One of the most powerful and poignant Rounds I facilitated with a colleague was the first anniversary of the Grenfell fire. 142 people attended including many doctors and nurses. The pain in the room was palpable. Some people said they had not talked about the disaster since that fateful day in June 2017. The evaluations were outstanding. Another more recent Round concerned the tragic consequences of knife crime and the sorrow of treating both the attacker and his victim (who later died). Both of them only 17 years old – young lives lost or ruined in a moment of thoughtless rage.

The evidence of benefit for staff, patients and the organisation

Schwartz Rounds are not the panacea for some of the entrenched systemic problems in the healthcare service, but they undoubtedly create a more nurturing environment and help to humanise healthcare, steering it away from a depersonalised system to acknowledging, as well as honouring, the care in caregiving.

Schwartz Rounds have now been running in the USA for more than 20 years and have been independently evaluated and found to decrease stress and isolation,
improve understanding of colleagues’ roles and contributions, increase feelings of being supported and empowerment to provide compassionate person-centred
care (Lown and Manning, 2010). Researchers in the UK also found that Rounds improved communication, trust, openness with colleagues and enabled more
compassionate care (Farr and Barker, 2017).

A more recent realist-informed large-scale mixed method (qualitative and quantitative) evaluation conducted in England for the National Institute for Health
Research (NIHR) by Maben and colleagues showed that attending and contributing to Rounds was associated with statistically significant improvements in staff wellbeing, and this effect was ‘dose dependent’ – the more Rounds attended, the greater the positive impact. They also found a significant reduction from stress from 25% to 12%. 10 key themes were identified:

1. Trust, emotional safety and containment.
2. Group interaction.
3. Countercultural ‘third space’ for staff.
4. Self-disclosure.
5. Storytelling.
6. Role modelling vulnerability.
7. Contextualising patients.
8. Contextualising staff.
9. Shining a spotlight on hidden stories and roles.
10. Reflection and resonance.

Other reported benefits included greater empathy and compassion for colleagues and patients, reduced isolation, enhanced peer support and improved teamwork, work engagement and communication with patients. The researchers concluded that Schwartz Rounds offer unique elements of support compared to other interventions.

Cath Taylor and colleagues undertook a systematic review of studies showing the impact of Schwartz Rounds on staff and compared Rounds with other interventions designed to provide staff support such as Balint Groups, mindfulness-based stress reduction (MBSR) training, critical incident stress debriefing (CISD), resilience training and reflective practice groups (Taylor et al, 2018). The evidence base regarding effectiveness of these interventions is weak overall, but the researchers (rightly in my view) assert that employers should still provide supportive interventions and that clinical supervision should be available for doctors and nurses, just as it is for mental health nurses, psychologists, midwives and social workers. They point out that non-clinical staff such as hospital porters and cleaners who have frequent contact with patients are even more neglected. The researchers emphasised the importance of skilled facilitation for
successful Rounds. They conclude that, ‘Rounds offer a unique organisation-wide “all-staff” forum to share stories about the emotional impact of providing patient care’. Organisation-wide interventions are arguably more likely to change cultural norms and attitudes towards vulnerability. They can also break down silos, developing cohesion between and within groups, and nurture compassionate cultures.

Are Schwartz Rounds ‘counter-cultural’?

Rounds are counter-cultural in a number of ways. Firstly, they are grounded in the social, emotional and relational aspects of care rather than the more functional, transactional and rationally calculable ‘performance monitoring markers’ (targets, efficiency, etc) characteristic of the new public management (NPM) and prevalent in NHS health policies (Farr and Cressey, 2015). Secondly, they allow for the disclosure of vulnerability – a rare phenomenon in healthcare institutions, perhaps more so in some specialties such as surgery, where the mythical imagery of invincible heroism, or the promotion of military stoicism, are prevalent. These ‘metaphors of practice’ can create unreasonable expectations both from clinicians themselves and from their patients. When a senior clinician reveals his grief and even cries in a Round, the impact is considerable – junior staff realise to their relief that they are not alone in experiencing distress, but more importantly this distress does not prevent the clinician from being a competent professional able to deal with emotionally laden emergencies. These disclosures also create a sense of common humanity and shared compassion – a recognition that we are all subject to suffering and are to a greater or lesser extent wounded healers (Egnew, 2009). Thirdly, Rounds eschew unhelpful linear solutions to complex problems and don’t even attempt to ‘fix’ things – a mindset that is prevalent in modern medicine. Fourthly they encourage ‘slow medicine’ – giving space for reflection (and even silence) rather than the normal fast, efficient task-focused approach. Finally, but importantly, Rounds are subversive as they can flatten hierarchies. A hospital porter’s story may be valued as much as that of a senior clinician. A medical student has the opportunity to voice her concerns and will be listened to respectfully and seriously.

The power of stories

Humans are natural storytellers (Gottshall, 2012). We tell stories to make sense of our experiences and the world we live in. Stories give us meaning and coherence. As Arthur Frank in The Wounded Storyteller tells us, ‘Thinking with stories is the basis of narrative ethics… Stories are the ongoing work of turning mere existence into a life that is social, and moral, and affirms the existence of the teller as a human being’ (Frank, 1995). A strong line of research shows that if storytellers can derive redemptive meaning from suffering and adversity in their lives, they tend to enjoy higher levels of wellbeing, psychological growth and other indices of successful adaptation (Fivush, 2017). Schwartz Rounds tap into this rich source of strength and resilience.

Practical aspects and further developments

Schwartz rounds can take time to become mainstream in healthcare institutions and senior management support is essential for success. Timetabling has to be organised so that people are not locked in shifts that preclude attendance. Positive feedback via word of mouth has led to a snowball effect with rising popularity and attendance. Smaller, briefer ‘pop-up’ Rounds can be organised for those who have difficulties attending the usual venue. Rounds are being held in settings other than hospitals, such as hospices or primary care. Administrative and mentoring support is needed for the smooth functioning of the system and for facilitators to confidently develop in their roles. Medical schools are now developing and running Rounds increasing the likelihood of cultural shifts from the ground up (Barker et al, 2016; Stocker et al, 2018). More research is needed to explore further the impact on organisational cultures and individuals as well as patient outcomes.

Conclusion

Schwartz Rounds act as containers and crucibles. They are containers in that they offer a boundaried, safe space for articulating and regulating emotions that would otherwise be suppressed, hidden or ignored, and they enable individuals to create and listen to powerful healing stories and to share perspectives. They are crucibles for creating new ways of looking at oneself and others, for exploring in more depth the healing work of medicine, for witnessing both suffering and joy and for fearlessly accepting the light and the dark side of working in healthcare. They also act as mirrors, enabling greater self-awareness and shared reflection. Rounds enable one to see more clearly the patient in the person and the person in the healthcare professional. They remind all those working in an
organisation that they share a common humanity and a common purpose.

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