Beyond Compassion Fatigue: The Systemic Origins of Compassion in Medicine

Abstract

Compassion is the heart of medical care. Doctors want to practice with compassion and patients expect to be treated with compassion. Despite its importance, however, research has historically fixated on compassion fatigue, a type of burnout among medical practitioners, and neglected the study of compassion itself. Perhaps more to the point, the absence of empirical work regarding the origins and impediments of compassion has made the development of targeted interventions to enhance compassion difficult. Indeed, the literature on medical compassion has been based primarily on opinions and value-guided suggestions with no clear evidentiary basis. It was in the context of this background that a programme of doctoral study investigating 1) the barriers to compassion in medical practice and 2) interventions to enhance compassion in medicine, was developed. To address these two aims, the thesis is divided into two sections. In the first section, the thesis begins by proposing a contextual model of compassion, the Transactional Model of Physician Compassion, which provides a framework in which physician compassion emanates (or does not emanate) from four distinct, but interrelated variables – the physician, the patient and family, the clinical situation, and the environmental contexts where compassion takes place. Having proposed a theoretical framework for organising the influences on compassion, two empirical studies that investigate the barriers to care are presented. Study 1 (N = 372 Filipino physicians), describes the development and early validation of an instrument designed to assess impediments to doctors’ compassion – the Barriers to Physician Compassion Questionnaire. In line with expectations, this study found that barriers to compassion were not one dimensional, and instead had four components: physician, difficult patient and family, complex clinical situation, and external factors. Given the suggestion that the context in which medicine are important to the experience of compassion, Study 2 (N = 580 New Zealand physicians) extended the development study by testing whether the barriers to compassion varied as a function of medical specialisation or physician experience. Broadly, this report found that psychiatrists reported the lowest barriers while general practitioners reported the most. Importantly, in terms of beginning the process of illuminating the origins of compassion’s barriers (and inconsistent with “fatigue” based models), the barriers to compassion were consistently lower in doctors with more clinical experience. The second half of the thesis addresses the second aim of this programme of doctoral study, which is to consider and preliminarily test interventions to enhance medical compassion. Since compassion is a systemic problem that warrants a multi-factorial approach, the section begins by recommending practical suggestions, as informed by the Transactional Model of Physician Compassion, to enhance compassion in general practice. These recommendations focused not just on the doctor (e.g., mindfulness training and practice), but also included suggestions that addressed patient and family, clinical, and external factors. Since mindfulness appears to enhance compassion in non-medical populations, suggestions on how to incorporate mindfulness in day-to-day surgical practice were proposed. Though mindfulness appears promising as engendering compassion, empirical work examining the effects of mindfulness in physician or medical trainees’ compassion is lacking. Thus, Study 3 tested whether a brief mindfulness induction increased compassionate responding among 83 medical students as well as whether trait selfcompassion moderated the effect of the experimental manipulation. Analyses showed that mindfulness increased self-reported patient liking and caring but only among medical trainees with low self-compassion. Conversely, the experimental manipulation of mindfulness also predicted greater helping behaviour among students with higher self-compassion. Taken together, these studies are the first to demonstrate that compassion in medicine can and should be studied as an empirical endeavour rather than either simply asserting it as a value or studying its absence. The sum of these works suggests that compassion in medicine is not all about the doctor, but that multiple variables within and outside the doctor are dynamically interrelated and influence the genesis of compassion. Mindfulness shows some promise as an intervention but since the barriers to compassion also rest within the patient and family, the clinical situation, and external factors, interventions targeting other barriers are also warranted. While challenges remain in studying compassion in medicine, this thesis has shifted the view of medical compassion from simply being value-based and aspirational, to an organized theoretical framework and empirical body of knowledge to relieve human misery and pain.