By David C. Leach
An old joke begins by asking that you imagine a man drowning 100 feet offshore while a conservative and a liberal are observing. The conservative throws him a 50 foot rope and says: “swim the extra distance, it’s good for you.” The liberal, on the other hand, throws him a 100 foot line and then promptly drops his end of the line in order to go and do another good deed.
While offering insight into our politics the story also illuminates some of our habits around caregiving in our current healthcare system and the policies supporting that system. Certainly individual stories of near heroic caring can be found, but the system itself is designed around processes and structures that seem to diminish the importance of the caring relationships at the heart of our work. Caregivers frequently depend on work arounds. What would it take to develop a system that respects, rewards, or at least enables genuine caregiving?
Caregiving, of course, is an attribute of humans, not systems. To care for another requires a voluntary opening of the heart to compassion; it requires noticing and acknowledging the uniqueness of the other and a willingness to enter into their context. Keenan defines mercy as the willingness to enter into the chaos of the other. (1) The biblical story of the Good Samaritan (Luke, 10:33) illuminates an interesting attribute of caregiving that may indicate why humans can care and systems cannot; the clue is in the voice of the verbs used. The story is well known: a traveler has been assaulted and robbed. Two others pass by without helping while the third, a Samaritan, “was moved by compassion” and stopped to help. I believe that the passive voice of the verb is not an accident. The first step in caring is to allow oneself to be moved by compassion. “Be compassionate” doesn’t fit naturally on a to do list; the initial step is not a “doing” but an emergent openness when one has been moved. Subsequently there may be many action steps, but it starts by being moved by something greater than the caregiver…
Humans can be moved, systems cannot. Caring transcends systems, however, systems can either enable or disable caring. While systems can’t be moved, they can be redesigned. The psalmist advises: If today you hear his voice, harden not your hearts (Ps.95). Systems can create heart-hardening ecologies. They can make it hard to discern the voices of patients, families, and other caregivers; they can encourage a dismissiveness that amounts to heart-hardening.
Sometimes the heart-hardening features of healthcare systems are so pervasive and impervious that the situation can seem hopeless, however, three features of the healthcare system offer potential as enablers of caring. First and foremost is the link between health professional formation and healthcare. Reflect on your own experience. Working alongside a truly compassionate doctor or nurse is a life changing event. I can name the exemplars in my professional life even now, decades after my training. Many of my mentors had succumbed to the hardened heart syndrome, but the effect of their cynicism on my own formation was nothing compared to the professional joy I experienced working with compassionate caregivers. The combination of superior intellect and genuine goodness is immensely attractive. We want to be like that. Being more explicit about the link between caregiving and the formation of health professionals at all stages of development enables both better care and better formation.
A second opportunity emerges from the first. We should select people who have demonstrated some interest, experience, and facility with caregiving. This requires more than reading the “I want to help people” statements on medical school admission essays. In the past – the long ago past- some medical schools would ask prospective applicants to work in the hospital for a year as an orderly before starting medical school. Learners discovered whether they could stomach the actual nitty-gritty of care and the schools could make their decisions based on more relevant data than they now have access to. Perhaps premed should be reduced to three years of college followed by a one year paid experience reporting to and assisting the nursing staff in our hospitals. Relieving student debt while offering the substrate in which to practice caregiving might enable better selection of health professionals.
The third potentially enabling feature involves acknowledging the reality that healthcare is a cooperative rather than productive art. We don’t produce a pound of healing, instead we cooperate with the body’s natural tendency to heal. P aul and Maren Batalden’s work on the coproduction of healthcare implies that we must pay more attention to the various relationships in healthcare. (2) The doctor-patient relationship of course, but also the relationships between all of the involved health professionals and also the relationship between the profession and society. Healing turns out to be a communal event.
We are all vulnerable and are at our best when we help each other with our weaknesses. While we need objectivity to be most helpful, we need genuine compassion to be most human. Managing this paradox is the task before us. Systems designed to support our formation, our relationships, and our cooperation can enable better caregiving.
David C. Leach MD, was trained and practiced as an endocrinologist. He served as the Executive Director of the Accreditation Council for Graduate Medical Education (ACGME) from 1997 – 2007. He is a member of the Board of Trustees of Mercy Health. He serves on the Editorial board of Reflective MedEd.
- James Keenan. The Works of Mercy: The Heart of Catholicism. Rowman and Littlefield Publishers, 2007.
- Maren Batalden, Paul Batalden, Peter Margolis, Michael Seid, Gail Armstrong, Lisa Opipari-Arrigan, Hans Hartung. Coproduction of Health Care Sevices. BMJ Quality and Safety. 2015, http://qualitysafety.bmj.com/content/early/2015/09/16/bmjqs-2015-004315
3 thoughts on “Caregiving: Can It Be An Attribute of Our Healthcare System?”
“Caregiving”in medical practice goes beyond diagnosis and treatment but must also involve “patient-centered care”. An example of such attention and care is the topic of my posting yesterday to Dr-Ed, education listserv of MSU.and reference to an article in the AMA Journal of Ethics. I will reproduce my posting below as an example which I think would meet Dr. Leach’s definition of necessary patient “caring.”
.Maurice Bernstein, M.D.
Associate Clinical Professor of Medicine
Keck School of Medicine
University of Southern California
“Bioethics Discussion Blog”
If I failed previously to bring up the topic of consideration and teaching of the issue of patient requested gender– concordant care in terms of 3rd and 4th year medical students but also beyond as physicians, I apologize since I think this matter is of great importance. First of all I am virtually being daily bombarded by my visitors to my Bioethics Discussion Blog volumes on the topic of Patient Modesty http://bioethicsdiscussion.blogspot.com/2017/04/patient-modesty-volume-79.html who insist that the medical system is inadequate in teaching and practicing this important possible patient request. And the matter of being medically attended by individuals of the same gender as the patient is extended beyond just physicians but also medical students, nursing and technicians and scribes within the medical care system whether in hospital or office.
In view of this crying out by the public on my blog now for 12 years (!), I was pleased to read an important article in the AMA Journal of Ethics April 2017 titled “How Should Physicians Respond When Patients Distrust Them Because of Their Gender?”http://journalofethics.ama-assn.org/2017/04/ecas2-1704.html
The Conclusion of the article: ”
In summary, patient requests for gender-concordant student care present challenges and opportunities for medical students, physicians, and institutions to simultaneously promote patient-centered clinical care and training in medical professionalism. There are many reasons that patients may request gender-concordant care, and how institutions and clinicians address these requests requires thoughtful engagement with the ethical principles of patient well-being, respect for persons, and fairness. Medical students should acknowledge their emotional responses to the situation, promote the primacy of patient care, and seek help from their attending physicians, clerkship directors, and institutions in navigating these clinical scenarios.”
What are we doing in medical education to contribute to the matter of gender-concordant care if requested by the patient and really attend to this aspect of the concept of “patient-centered care”? ..Maurice.
Thank you Dr. Leach for this poignant and insightful wisdom. I’ve been a fan of yours since “Transcendent Professionalism” http://bit.ly/2sAW0fD
Your comments in this blog resonate for me with themes that emerged as central to healthy professional identity formation (PIF) in the Academic Medicine PIF theme issue : reflection, relationships, resilience. http://bit.ly/2jZoroO
Reflecting on who we are becoming within lifelong PIF- how are we doing with our learning environment (positive?), with fostering authentic, caring and compassionate relationships with peers, interprofessional care team members, trainees and patients (and ourselves!) and in that vein, with our own emotional, moral, and spiritual resilience all of which impacts compassionate and competent care? Your blog reminds us that we must remain ever vigilant within training and organizational systems design for delivery of such care for the good of suffering patients and their families. It is a shared humanity.
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