In this series, AMS Healthcare addresses the challenges facing healthcare today – particularly in light of the COVID-19 pandemic. The AMS Community promotes compassionate care, development of the leadership needed to realize the promise of technology and the understanding of how our medical history influences the future of our healthcare. A new piece will be posted every Friday on Healthy Debate.
A “sense of compassion” is an expected attribute of a competent healthcare professional. Students are expected to be “compassionate” as they begin their clinical journeys in the health professions.
We have been reflecting on how we “teach” and “assess” compassion within our own curricula. Interestingly, the Competency Profile for Physiotherapist in Canada does not explicitly state compassion as a competency, focusing on “empathy” and “respect” under the communicator role. The Essential Competencies of Practice for Occupational Therapists in Canada mentions “compassion” as one of the cues, along with confidentiality, transparency, disclosure, integrity, honesty and respect, as performance indicators of “assumes professional responsibility: demonstrates a commitment to clients, public, and the profession.” Within the CanMeds competency framework, “compassion” is included under the medical expert role as a feature of the “commitment to high-quality care of patients” and under the communicator role as a feature of a “patient-centered approach to communication that encourages patient trust and autonomy and is characterized by empathy, respect and compassion.” Clearly compassion, although expected, is not consistently stated as an entry-level competency in health professions.
There is also debate on whether compassion can be “taught” and “assessed” as a competency. In their 2014 paper, Compassion: Wherefore art thou?, Lorna Devon and Jill Thistlewaite highlight the wide divide regarding the “teachability” of compassion: while Stanford University has a centre dedicated to research and education on compassion and altruism, others have argued that students in the health professions are taught “not to care” due to the neglect in teaching “how to care.” Therefore, the possibility that we might be failing to educate students how to be compassionate healthcare providers must be considered as this could be a contributing factor to compassion fatigue and burnout.
A first step is to consider what compassion “is” and how it can be “observed” in practice. According to the Oxford English Dictionary, compassion means “to suffer with.” It has also been defined as “the feeling that arises in witnessing another’s suffering and that motivates a subsequent desire to help.” Compassionate care therefore lies at the intersection of “empathy,” which is understanding and the moral judgment to act, and “sympathy,” which is feeling.
How can such a complex phenomenon be taught and observed? Neuroscience might provide a solution as neuroscientists have identified distinct brain networks activated by “empathy” or “compassion” training.
Empathy training activates brain networks associated with self-experienced pain and a general negative effect. As such, empathy training, which emphasizes intense sharing of another’s pain, can lead to “empathetic distress” and “decreased helping behaviour.” In comparison, compassion training activates brain networks related to reward, love, affiliation (social connectedness) and overall positive effect. As such, compassion training could buffer a negative “empathetic” state. Moreover, the sense of reward and affiliation associated with compassion training could be effective in engaging students to take action to alleviate another’s suffering.
The technique used for compassion training is based on an Eastern contemplative tradition. This approach aims to “foster an attitude of friendliness toward oneself and others” by cultivating “the capacity to experience care and warmth, even when faced with one’s own suffering or the suffering of another.” Through guided visualization, students reflect on their own past suffering and learn to relate this experience to feelings of warmth and care and, thus, to feel safe despite suffering. Participants are then guided to extend this caring experience toward a close person, a neutral person and finally toward strangers and humans in general.
The effectiveness of this guided visualization should be considered for the teaching of compassion within the health professions. Currently, three principal approaches are used to teach compassion in the health professions: person-centered communication skills, reflective practice and compassionate role modeling. Of these, self-reflection lends itself well to including guided visualization to derive the neuroplastic benefits of compassion training. Such guidance would need to lead students to explore and rationalize their feelings of “safety in compassion.” The dialectic method of Socrates may be appropriate here.
In the Socratic approach, the teacher uses open-ended inquiries to enter into a dialogue with the student to stimulate deeper thinking and self-understanding. Used within the context of guided visualization and self-reflection for the teaching of compassion in the health professions, the Socratic approach could help students explore the boundaries within which they would feel sufficiently “safe to act” in relation to their own suffering and the suffering of others.
Therefore, we argue compassion “can” be taught in the health professions through guided visualization and self-reflection that would lead students to develop a “sense of safety” while acting to relieve the suffering of another as well as one’s own suffering. The development of novel assessments that focus on boundaries of an individual’s perceived safety could be effective in determining “readiness” for compassionate practice in the health professions.
“Perhaps what differentiates highly creative ideas from ordinary ones is some combined sense of beauty, simplicity, and harmony,” states Douglas R. Hofstadter in his Pulitzer Prize-winning book Gödel, Escher, Bach.
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Dear Dr. Pelland and Dr. Batorowicz,
This exploration regarding whether or not we can teach and assess compassion as a competency was encouraging. Furthermore, I was heartened to see you suggest a dialectic approach to developing compassion. I personally have been engaged in some of the practices geared towards developing compassion, including one that has been systematized by the team you mentioned at Stanford which is known as Compassion Cultivation Training (CCT) program. Although my experience is quite limited, I can attest to the fact that these practices complied in the CCT program truly depend on ones ability to reason, re-contextualize, and change perspectives. The program’s protocol suggests that when compassion is grounded in a sound reasoning process, it can become integrated into ones basic outlook through a process of familiarization. I encourage anyone interested in this topic to consult an excellent book by the principal author of the CCT program, Dr. Thubten Jinpa, entitled “A Fearless Heart”.
Lastly, I’d just like to mention that as a new student in the School of Rehabilitation at Queen’s (GDip AGHE), I feel very proud to see these types of conversations happening here.