Compassion: What is it? Why is it Powerful? What is its Threatened Role in Medicine?

Having compassion is a way of being, thinking, and acting that can be easily misunderstood and misidentified.  To show compassion is a way to make the lives of people who receive it better, while also increasing happiness, wellness, joy, and contentment, for the giver as well. 

Compassion has been written about and practiced in the Buddhist tradition for thousands of years.  It has even been a means of survival for Buddhist monks during times of persecution and strife.  In our fast moving times where people depend heavily on technology, are oriented more to self than other, and frequently declare a sense of entitlement, compassion for others is rapidly becoming a lost art and practice.  While some feel that you either are a compassionate person or not, depending on your genetic background, upbringing, and environmental circumstances, others feel compassion as a way of life can be learned and cultivated and strengthened by practice.  It is well worth the effort according to Lorne Ladner, Ph.D. who states in his book, The Lost Art of Compassion that “..compassion is the most exalted of all states of the heart or mind.” (p. 10).  There is no doubt that compassion can put a positive spin on our lives, enriching them, making difficult circumstances more bearable, and possibly even enjoyable.

Compassion has a key role to play in the practice of effective medicine, but, as discussed below, its importance is increasingly and paradoxically deemphasized , while great advances continue to be made in the scientific and technological aspects of modern medical care.  This situation has led to dissatisfaction among doctors and patients alike, who both feel that something is missing in the way medicine is practiced today.

So what is compassion?  It is essentially the recognition of the suffering of another and the wish to relieve that suffering and remove the cause of the suffering, if possible.  In the words of Robert A.F. Thurman, Professor of Indo-Tibetan Buddhist Studies at Columbia University, “To feel compassion, you must turn away slightly from you own focus on superficial happiness to sense the true condition of others, honestly facing their pains.” (In the Forward to The Lost Art of Compassion, p. ix).

It’s not only recognizing the suffering of others, but, as mentioned, wanting and trying to relieve it as well, so that the suffering person is better and happier.  Although there can be no compassion without empathy first, the two are not synonymous.  Empathy, as discussed in the last column, is the ability to understand and accept another person’s emotional experiences, feelings, thoughts and perspectives in a non-judgmental way.  Compassion is the ability to appreciate and recognize the other person’s suffering that may be related to those thoughts or feelings or also to difficult experiences or life circumstances, physical or emotional pain, illness, or loss.  Empathetic understanding of the person fosters the development of compassion.

Another word that is frequently confused with compassion is altruism, which is the actual act of helping another.  Dr. Ladner talks about the fact that compassion cannot actually be measured because it is a “state of mind and heart” that is felt and is not actually quantified by the good deeds themselves.  Interestingly, even if someone does a good deed, if it is done because of self-interest or secondary gain to impress someone or out of obligation, it is really not an act of compassion.  So to summarize, one can be altruistic without being compassionate (although the best scenario is to be altruistic and compassionate together), but it is difficult to be compassionate without also being empathetic.

What are the benefits of compassion to the receiver and giver?  The receiver can sense positive change if the giver’s compassion leads to acts that relieve the receiver’s suffering.  The receiver can also develop an improved sense of self-worth and more confidence that can come from support.  Compassion can create that sense of human connection that we all long to experience.  Compassion can create hope in the receiver and foster a sense of resiliency, allowing the receiver to use qualities and strengths that may have been hidden.  Compassion may lead to good communication and honesty and a shared sense of humanity between the two parties.  Compassion may also encourage affection.  For the giver, compassion may result in a sense of joy and happiness, because of the positive feelings compassion engenders.  Many feel this state of joy can lead to positive psychological and physical health.  And finally, as will be discussed below, it is valuable if the giver can tap into his/her own sense of suffering or memories of suffering in the past to connect with the suffering of the receiver.  This can allow the compassionate person to gain perspective on his/her own life as it is now and foster an appreciation of and gratitude for what is now in the moment.

So what does one do to develop compassion?  Dr. Ladner maintains that the first step to take is confront your own narcissism or self-centeredness or self-involvement.  We all have a certain amount of this, more prominent in some than others.  But true compassion is the opposite of narcissism, according to Dr. Ladner.  He suggests imagining what the person’s suffering must be like and what it would take to relieve that suffering.  Then imagine giving that person happiness.

If you practice this approach, it increases your own feelings of compassion “and you become more willing to do things for others.  When people develop thoughts and ideas strongly motivated by compassion, external manifestations (large and small) of these ideas naturally flow as well.” (p.247).  Compassion for others can certainly make their suffering more bearable, but it doesn’t always involve doing or saying something.  Just being with someone and showing compassionate presence can be enough.

Part of the problem of being compassionate with others and dealing with their suffering is facing our own vulnerabilities for suffering, illness (physical or mental), loss, and death.  Dr. Ladner in The Lost Art of Compassion calls this our “narcissistic self-image” – our effort to maintain the ideas that we are not vulnerable, fragile, or even mortal with a limited time of survival.  The interesting thing is that if we confront both the fears we have about these issues and our own potential for suffering, it becomes easier to be concerned for another’s suffering, because of the identification of this commonality we all have.

What other barriers exist to the experience and practice of compassion?  Dr. Ladner talks about a few in his book.  One of the biggest barriers is stress – it works against the development of any sense of compassion, especially if one is overwhelmed, unhappy, and unable to connect with others because of stress.  Wanting to be liked and seeking the approval of others is another barrier.  When you are fully compassionate, you don’t have your own motivations and are not looking to fulfill your own needs.  In other words you are not looking for any rewards other than the good feelings and happiness that come from showing compassion to others.  Not taking care of yourself is another barrier to compassion.  Trying to take care of everyone else and solving everyone else’s problems without taking care of yourself and your own needs blocks compassion, because this situation can make one resentful..  As Dr. Ladner states, “You can’t give others what you don’t have yourself.” (p.25). “So wisely taking care of ourselves naturally becomes a way of taking care of others.” (p.27).  It is thus important in the act of showing compassion to know one’s limitations and capabilities and to set boundaries so that one’s own needs are not sacrificed.

It flows out of the above-mentioned concept of self-care that one must first have compassion for oneself before being able to show compassion toward anybody else.  This involves self-acceptance of the way you are, your strengths, your weaknesses, your accomplishments, your failures, and your human foibles.  Dr. Ladner also suggests that to develop compassion for yourself you must look to your own suffering and its causes, a potentially painful and frightening process that is difficult to do.

If you can then learn to liberate yourself from your own suffering, it frees you up to help others rid themselves of their own suffering.

And what is the role that compassion plays in medicine?  Ideally, it should be a major role, but with increasing demands from insurance companies and Medicare, electronic medical record keeping, doctor’s overly busy and overly extended schedules, greater number of patients, greater complexity of medical knowledge, medical choices, and medical care, compassion is falling more and more by the wayside.  The major misconception is that compassion is assumed to be a natural part of the medical process and encounter, because the aim of the doctor  is to lessen and improve the suffering of the patient.  As David L. Shlim, M.D. points out in his introduction to the book Medicine and Compassion (by Chokyi Rinpoche and David R. Shlim, M.D.),

“Doctors take for granted that by alleviating their patients’ symptoms they are expressing compassion.  Doctors tend to remain focused on the mechanics of medical care – diagnosis and treatment – and rarely spend much time imagining what it feels like to be a patient under their own care.” (p.3).  This is one of the reasons that patients today are frequently  unsatisfied and feel that modern medicine is very impersonal – they want to have some interaction with and compassion from their physicians, not just the relief of symptoms.  Doctors are frustrated as well, not receiving as much satisfaction from their careers because of the frequent lack of meaningful interaction with their patients and a growing awareness of how patients are not appreciative of and satisfied with the care they are giving.

What are the specific benefits that compassion from the doctor to the patient can bring into the relationship to help the patient heal or at least improve?  First of all, the patient may just feel better if he/she is shown compassionate caring.  The patient may also more easily develop trust, if the doctor is compassionate.  There may be better communication between the patient and the doctor when the patient  feels the doctor cares.  The patient may feel freer to express what is really bothering him/her and what his/her needs really are.  Confiding doctor-patient relationships can be very healing; compassion promotes this.

As Harvey V. Fineberg, M.D. and Donald E. Fineberg, M.D. point out in their Forward to Medicine and Compassion, “Compassion promotes confidence.  Compassionate physicians stay better focused on the true needs of their patients while taking full advantage of expert knowledge in treating them.” (p.4).  Compassion can also help reduce a patient’s anxiety about the unknown, because the caring doctor is there to help the patient face it.  A compassionate physician is better able to cope with the everyday stresses of medical practice and can deal better with the difficult demanding patient, the critically ill patient, and the terminally ill patient.

This is because of a more likely inner calmness and an appreciation of humanity in general and human suffering in particular.

Even though there is less time for physicians to spend with patients nowadays, a doctor can still have a compassionate attitude and a total dedication and motivation to relieve suffering.  Patients are very sensitive to this and can pick it up immediately.  And it can have therapeutic power as a result, because of the inherent reassurance to the patient.  Francis Peabody, M.D. in his famous article, “The Care of the Patient” (JAMA, 1927; 88:877-82) said, “One of the essential qualities of the clinician is interest in humanity.”  That is part of having compassion.

It is interesting and telling that the word ”compassion” does not appear as a definition in any of the medical dictionaries, while the definition for the word “empathy” does.  So why is compassion so frequently neglected in medical practice?  Some of the answers can be found in the environment both of medical school education and subsequent intern and residency training.  In an interesting and edifying study, “Can Compassion Be Taught?  Let’s Ask Our Students?” (J. Gen. Int. Med., July, 2008; 23:948-953), Delese Wear, Ph.D. and Joseph Zarconi, M.D. questioned 112 fourth year medical students about whether formal and informal educational experiences fostered compassion, altruism, and respect for patients during their preclinical and clinical years.  Their publication was based on the results of only 46% of the students, the number who consented to have their questionnaires discussed in the paper.

Even with that in mind, the results were illuminating.  Most students mentioned their parents, background, and upbringing as important influences in instilling compassion and altruism before they came to medical school.  In the preclinical years, some found that courses in bioethics, behavioral sciences, and humanities were helpful in teaching them about being aware of people’s lives and opinions, but others felt it didn’t affect the degree of compassion they felt , because they already were compassionate and found the courses promoted “appearances” of being compassionate rather than compassion itself.  The preclinical educational environment was felt to negatively influence the development of compassion, because the emphasis was on competition, succeeding, and personal gain.

In the clinical years, the students considered role modeling by practicing physicians to be a major positive influence in helping them develop their sense of compassion and altruism.  However, not all role models were ideal, and there weren’t opportunities to question the behavior of these physicians, particularly since there was a feeling that to do so  would affect their grade.

In the actual clinical environment of working in the hospital, the students felt there were many negative influences that worked against their developing any sense of compassion.  “Fatigue and overwork” were two of those factors, but the emphasis on “efficiency” in how you functioned in doing your work was a major deterring factor.  Getting the job done as quickly as possible was so encouraged that the focus was more on the patients’ diseases and what to do about it rather than the patients themselves.

One student commented, ”It is easier to shut off your emotions and get through the work as efficiently as you can…It all boils down to putting yourself, your time, your work before the needs of your patient.”  The lack of focus on and encouragement of self-evaluation were cited as blocking the development of compassion as well.  One student wrote, “The busier we become and the more important we view ourselves, the less time we have for introspection and reflection, both of which are necessary for character growth and virtue development.”  This emphasis on making the grade and getting a good score is part of what is called “The Hidden Curriculum” in medical school.

The authors of this study suggested some solutions for these problems.  They felt a need not only for more positive role models who stressed compassion for and altruistic behavior toward their patients, but also the time to discuss with the students how the compassion was conveyed to the patients and why the role model physicians interacted in the way they did and said the things they said.  To have the opportunity to talk openly about positive aspects of the doctor-patient interaction would be very helpful for students.  The authors’ second recommendation was “designing opportunities for critical self-reflection in safe places with trusted faculty throughout the curriculum.”   This would give students the chance to discuss their positive experiences and vent about the negative experiences in a supportive environment that would not affect their grade or where “fitting in” with the clinical environment they were experiencing would not be an issue.  This would require developing a faculty who would be supportive mentors and whose values would reflect compassion in patient care.

There is an elective course now taught in over eighty medical schools that addresses these issues.  It’s called “The Healer’s Art” and was developed in 1993 by Rachel Naomi Remen, M.D., a phenomenal and compassionate physician whom I frequently quote in my columns.  Five or six first or second year medical students meet with a faculty member who, as described by Dr. Remen, brings “presence, natural compassion, sensitivity, and honesty” to the group for five sessions of three hours each.  The aim of the course is to “explore the human dimensions of the practice of medicine.”  Students are encouraged to form “genuine interpersonal connections” with each other and “express their natural compassion” in a way that is supported and validated.

More of this type of work is essential, so that the compassion students bring with them to medical school can be supported instead of squashed.

In the internship and residency years similar problems work against the development of compassion in physicians.  Fatigue and stress related to working hard taking care of many patients do not foster the feeling of compassion.  There is again an emphasis on efficiency and getting the job done which can lead to neglecting what may be the patient’s underlying emotional needs.  Also, testing and technology today have become the center of medicine focusing on the disease only, so that very often the patient’s disease is treated, but not the patient him/herself.

Dr. David Shlim, in Medicine and Compassion, poignantly comments on his training as a physician by stating, “ But compassion had been slowly leeched from my system during my years of medical training, replaced by the persistent thought: it’s either them or me.  The patients, whose suffering was supposed to be my main concern, had become instead the source of my suffering by preventing my sleep, by having emotional needs I couldn’t meet, and by failing to get better while I was taking care of them.” (p.2).  The answer to this problem, Dr. Shlim mentions, is working on developing compassion as a way of life and as an attitude.  Rachel Naomi Remen, M.D., in her workshops with healthcare professionals, says how important it is to focus on the idea of service in order to prevent burnout.

She also stresses how vital it is for physician colleagues to talk with each other about the positive work they do for patients and the meaning it gives their lives and also share with each other the stresses and human aspects of being a doctor.

Finally, there are three other factors that work against a practicing physician’s expression of compassion.  One factor is just the lack of time to spend with patients in the current medical climate.  It takes time to get certain medical tasks done, and compassion can easily take a back seat.  Another is the failure to recognize the importance of humility in the practice of medicine.  As Jack Coulehan points out in his article, “On Humility” (Ann Int. Med. 2010; 153:200-1), humility in physicians should not be based alone on the fact that medicine is an imperfect science and art, but rather on the importance of “unflinching self-awareness, empathetic openness to others, and a keen appreciation of, and gratitude for, the privilege of caring for sick persons.”  All of these elements are essential for having compassion.  Dr. Coulehan suggests that in the present medical culture, humility is often regarded as a weakness instead of a characteristic that requires strength and resilience.

The other factor that can hinder a physician’s development of and expression of compassion is found in the nature of suffering itself.  Most people don’t like to ponder suffering and dwell on how it feels to suffer; in fact, we tend to run away from suffering as much as possible.  And yet, Chokyi Nyima Rinpoche says , when talking about the development of compassion in Medicine and Compassion, “The first step is to learn about suffering, to educate oneself about how illness feels…Just applying medical knowledge cannot fully relieve the sense of suffering experienced by many patients…Once we truly understand how illness is experienced – the anguish and pain that is involved – we can more naturally respond with the wish to alleviate it.” (p.30).  He also comments that if a physician has been ill him/herself, then he/she will have more of a sense of the suffering an illness can cause.  This makes it easier to appreciate the suffering of patients.  Chokyi Nyima Rinpoche also recommends that if a physician has not had a major illness, then he/she should try to imagine what it would feel like to be ill, especially the emotional and mental aspects.  The concern about focusing on a patient’s suffering, while taking care of that patient, is the possibility of emotional burnout.  Hence the tendency for what was taught as “detached concern,” so that physicians could take care of the patient by not caring too much, as Dr. Shlim points out in Medicine and Compassion (p.4).  And yet, there can be a balance, if boundaries are kept for the physician’s emotional health and rational decision making, and compassion is practiced as a way of life, fostered by meditative relaxation and the development of tolerance and patience for others and concern for their welfare.

So compassion is essential for good medicine.  The role compassion plays in medical practice, and in all of life for that matter, is described by Dr. Rachel Naomi Remen in two quotes:

“We thought we could cure everything, but it turns out we can only cure a small amount of human suffering.  The rest of it needs to be healed.”

“Perhaps the final step in the healing of all wounds is the discovery of the capacity for compassion, an intuitive knowing that no one is singled out in their suffering, that all living beings are vulnerable to loss, attachment, and limitation.  It is only in the presence of compassion that we can show our wounds without diminishing our wholeness.”