The Complexities of Compassion in Patient Care

The practice of medicine is an art, not a trade, a calling, not a business; a calling in which your heart will be exercised equally with your head.^1(p386)

William Osler, MD, 1849-1919

The eloquent and provocative insights of the renowned physician William Osler imply that medicine cannot be viewed exclusively as a data-driven entity. Today, business is substantially intertwined with the medical system. Yet, at the core of the day-to-day care of patients, there are a myriad of human interactions. They incite an awareness of suffering in its many forms, including the physical, psychological, social, financial, and existential aspects of illness. The scientific and technological response to the anguish of illness may at times substitute for or overshadow attention to the heartfelt reaction that Osler considered so important.

Many terms have been used to describe this heartfelt response including compassion, kindness, empathy, understanding, and humanistic attitudes. Compassion—“a sympathetic consciousness of others’ distress together with a desire to alleviate it”²—is arguably an integral component of optimal medical care. A recognition and alleviation of patients’ distress and an awareness of its broader effect on family members is a goal that many physicians strive to attain.

Yet, unfortunately, a seamless integration of compassion with the scientific and business components of medicine has yet to be achieved for multiple reasons. The current focus of medical education, the subjectivity of the compassionate interaction, the personal impact of compassion on the physician, and other barriers to a compassionate approach may all contribute to this lack of integration.

Medical education of physicians concentrates on the application of objective scientific data and implementation of guidelines to enhance patient care. There has been less emphasis on compassion and related topics partly because of the relative paucity of objective data that is inherent to the practice of medicine. Yet, there is an increasing acknowledgment that the humanistic attitudes of physicians make up an important aspect of health care. Some suggest that the inclusion of a strong patient- and family-centric educational focus could revolutionize medical education.³ Others might argue that compassion is an innate quality and cannot be taught. However, recent data suggest the contrary.⁴

The nature of compassion in the patient-physician relationship involves a complex subjectivity on the part of both the physician and the patient. Physicians may exemplify compassion in a manner that they perceive as optimal, but it may not be perceived in the same way by the patient. A multitude of factors may theoretically affect the physician’s manifestation of compassion. These include the physician’s degree of belief in its value, overall well-being, quality of communication skills, and sensitivity to the patient perspective, as well as the specific focus of the interaction.

The patient’s perception of physician compassion may likewise be hypothetically influenced by issues such as content of the interaction. In addition, it is plausible that the patient’s expectations, general well-being, extent and stage of disease, age, psychological state, view of the medical system, and relationship with the physician could have a potential effect.

In this issue of JAMA Oncology, Tanco et al⁵ explored multiple variables in regards to the perception of physician compassion in patients with advanced cancer. In their randomized study, patients viewed 2 sequential videos (4 minutes each) of physician actors delivering information about treatment options. Physicians were perceived as more compassionate in the videos with more optimistic content and in the second videos. A patient’s higher level of trust in the medical profession correlated with a more favorable perception of physician compassion. Patients differentiated between the messages in the videos despite the relatively brief content. Although this unique study advances understanding of the complexities of compassion in medicine, it also provides an impetus for additional research. For example, would the patient perception be different with an in-person interaction, a longer discussion, a personal relationship with the physician, or at a different time in the patient’s illness?

The risk of burnout for oncologists is an ongoing concern.⁶ From a practical perspective, there is a necessity to maintain some level of detachment from the patient’s suffering. However, extremes on either end of the spectrum may be detrimental to the physician, as well as the patient; finding a balance is often a challenge. Although the extent to which a physician’s compassionate approach affects the risk of burnout is unclear, there is also a potential benefit for the physician. A deeper understanding of humanity and sense of purpose is possible. The renowned author and physician Viktor Frankl noted that “The meaning of the doctor’s work lies in what he does beyond his purely medical duties: it is what he brings to his work as a personality, as a human being, which gives the doctor his peculiar role.”^7(p119)

Barriers to a compassionate approach may also include the perception that it takes too much time or that it is not meaningful to the patient. In addition, self-reflection regarding compassion inevitably leads to the recognition, at times, of falling short of one’s best intentions. In a medical culture that strives for perfection and in which time constraints are commonplace, it is not surprising that compassion may be eclipsed by other components of medicine.

Further research is likely to enhance our understanding of the complexities of compassion in patient care. Yet, one has to wonder whether we have yet to fully appreciate the power of compassion in its simplicity. In an article that focuses on kindness in medicine, Pickering⁸ highlights a part in the book Oliver Twist by Charles Dickens. In the story, the beleaguered young Oliver encounters an old lady who “… gave him what little she could afford—and more—with such kind and gentle words, and such tears of sympathy and compassion, that they sank deeper into Oliver’s soul, than all the sufferings he had ever undergone.”^9(p437)

Perhaps Dickens understood what medicine at times finds so challenging: the universal and inexplicable nature of compassion at its core.

Corresponding Author: Teresa Gilewski, MD, Memorial Sloan Kettering Cancer Center, 300 East 66th St, New York, NY 10065 (gilewskt@mskcc.org).

Published Online: February 26, 2015. doi:10.1001/jamaoncol.2014.296.

Conflict of Interest Disclosures: None reported.