Sunday, May 19, 2013

High Touch: The Course in Compassion

Rebuilding a Curriculum of Caring for Healthcare

This essay was written as a project paper for for the Harvard University Advanced Leadership Initiative Fellowship in which I was a 2013 Fellow.

"May I see in all who suffer only the fellow human being" 
                                                             Maimonides                                                 
The Problem

Healthcare is broken and doctors are burning out.
That is the current mantra. Healthcare has gotten too expensive and impersonal, and there is inconsistent access to that care. Doctors are increasingly stressed and do not seem as engaged. Patients complain that their doctors are too busy and no longer listen. They ask, “Who will take care of me as a person and not just as a bunch of x-rays and lab test results?” I trust my doctor, but why does she seem so distracted and disengaged.” With all the technological advances of the last several decades, with genomics and PET scans, MRIs and super-subspecialists for every conceivable body part, what in the world is happening to the very doctors who care for us?  We have all this “High Tech,” but, where is the “High Touch?”  Is being a physician no longer a calling?  Has it become just another job?  Have patients become commodities? Why has doctoring gone astray?   

 Gaps

The American system of medicine has become organized largely as a disease-management system, and not as a health-care system, with diagnoses and treatments now reduced to an impersonal set of numerical codes. The concept of “caring” is no longer central to a discussion of “health care.” Patients are being viewed by their health care providers more as the sum of their diagnostic testing, or as the "I-patient," to use the term coined by Abraham Verghese M.D. of Stanford University, which is to say, the "virtual" patient, seen by the physician more through the lens of that physician’s pda, laptop or computer screen, and not as the real, live, hurting individual in front of them.

Of course, this is an oversimplification. There are legions of dedicated doctors who are serving an ever larger and aging population, and who do so with empathy.  But we as a society have indeed reached a watershed moment, a saturation point on many fronts. We now live ever more hectic and hurried lives, with hardly a moment to stop and reflect. With increasing demands on our time and resources, we have become more anxious, are getting less sleep, and are making poorer dietary choices. The cumulative effect of this leads to illness. However, when we get sick, we still want help, and we have come to expect that help to be prompt and caring. Yet, even when we do find that help, it seems to have become curiously robotic and disengaged.

It is crucial for the health care profession – now a health care system, comprised of collaborative teams of physicians, nurses, PAs, social workers, ethicists, and even economists – to remain focused, engaged, vibrant, and committed to caring. We cannot have it any other way. We cannot be a healthy society, with healthy citizens contributing to the success and happiness of that society, without an engaged health care team. We need to (re)-train physicians for a lifetime of caring, so that they continually demonstrate empathy in their work, and so that they themselves remain energized and happy in their careers, as this will improve patient outcomes over time.

Physicians cannot heal without caring, and they cannot care without first being informed by a core set of ideals that will carry through their training and into their professional careers.  Medical schools are set up to train physicians, and at many of them, there is already an awareness of these problems which I have outlined, and some initiatives are in place. But the system, engrained and with its own cultures and rituals and focused on disease management, has lost sight of its ideals, the ideals embodied in the Hippocratic Oath.

Solutions: Frameworks in Medical Humanities

We must re-embed a pathway of caring in our health care providers and transfer a lifelong set of skills that will inform them throughout their careers, certainly in the physicians who still lead the health care team. What is needed is an overarching and cohesive rubric, which I have entitled The Course in Compassion: A Curriculum of Caring (The Course). These skills can be identified, quantified and measured, and will populate The Course.  The Course will be divided into modules, and taught using an accepted paradigm in most medical schools, the Problem-Based Learning (PBL) format. Six core modules, which are termed “Frameworks in Medical Humanities,” would be taught over the four years of medical school in weekly two-hour sessions:

                Sensory experience                      Motor task

           Dance and Movement                  Motion Research

           Music Appreciation                      Rhythm/Melody-Making
                                     
           Narrative & Reflective writing       Diary-Keeping

           Mindfulness and Spirituality          Yoga/Meditation 
                                                                          
           Art & Aesthetic Appreciation        Drawing/Sketching

           Empathy Training & Acting          Care-Giving


Stakeholders

Patients, physicians and physicians-in-training (medical students and house officers), medical school administrators, curriculum designers, The Association of American Medical Colleges, state licensing boards, and insurance companies – each of these entities is a stakeholder with a say in physician education. Adopting The Course will require hours of time to teach its principles, hours that will have to be taken in part from existing core disciplines as anatomy, biochemistry, pathology, physiology and microbiology, as well as from time already assigned to the medical students for hospital wards and outpatient clinics. Conversations will need to occur at many levels to allow stakeholders to “buy-in” to The Course as a foundational aspect of medical education.

However, The Course does not have to be built “from scratch.”  There exist a number of programs which have pilot projects aligned with my vision and ideas. A number of medical schools, (Harvard, Yale, Weill Cornell, Johns Hopkins, Stanford, UCSF, and Columbia, inter alia), offer courses which champion aspects of The Course. These existing initiatives are already testing the “proof of principle” of The Course. They are virtually all elective (that is, they are not required to graduate), but they exist. Therefore, it is not necessary to “reinvent the wheel” to populate the syllabus of The Course. Rather, The Course would be populated with “best practices” from existing efforts in addition to new initiatives I would add that have not yet been created or tested.

As Harvard Business School Professor Rosabeth Moss Kanter has written, change is often a result of Big Vision and Small Steps.” The Big Vision is creating and curating The Course in Compassion: A Curriculum of Caring (The Course). The small, essential and crucial steps are to pilot a series of medical humanities courses in all six modules, and, utilizing longitudinal data analysis, create metrics to measure patient outcomes and satisfaction over time, and physician satisfaction through their careers.
 
Impact
 
“It is far more important to know what person the disease has than what disease the person has.”  
                                                             Hippocrates                                  
 
Medical humanism is a core set of ideals that should be taught from college through medical school, internship and residency, and that should continue to inform a physician through their career. Medical humanism serves as a beacon and lodestone for how physicians listen, respond and care for their patients, as well as providing a road map for the well-being of a physician’s own mind and body over the course of their professional lives. The Course in Compassion will be a foundational paradigm around which physicians can be better engaged, and more motivated and passionate about providing care. Patients will achieve better outcomes, and physicians and their healthcare teams will enjoy longer and more fulfilling careers. This is an initiative which can no longer be fragmented, ad hoc and elective. The Course must become the epicenter of medical education and professional practice.
©   Vincent P. de Luise MD FACS

3 comments:

  1. I certainly agree that students should always take a variety of classes, especially the type that promote self awareness and growth and foster compassion for fellow human beings and I am sure it will effect the end product, but I wonder how effective it is in the hustle bustle of the real practice, perhaps a combination of things,
    Maybe patience should have mandatory physicals or lose their insurance, so doctor and patient have correspondence and the patient would be connected to a health network via email with bimonthly posts that are relevant to health issue of that specific patient as well as other good health information, especially of the preventative type and a patient could email on emergency questions and get a response in a reasonable time as well as posting health events going on in that persons area and a doctor must teach a couple of strategies for dealing with stress so that it becomes second nature to the patient and must go through with patient at office and giving the doctor relief if stress with each patient he dies this!

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  2. Thank you for your thoughtful comments. Medical humanism is a set of core ideals, taught from college through the medical school and internship and residency years, that stays with the physician throughout their professional careers. Medical humanism serves as a beacon and a lodestone for how physicians treat their patients and take care of their own minds and bodies over their lives. Thank you for commenting.

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  3. Maybe patience should have mandatory physicals or lose their insurance, so doctor and patient have correspondence and the patient would be connected to a health network via email with bimonthly posts that are relevant to health issue of that specific patient as well as other good health information, especially of the preventative type and a patient could email on emergency questions and get a response in a reasonable time as well as posting health events going on in that persons area and a doctor must teach a couple of strategies..

    health and social care courses

    ReplyDelete