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.

References

1. James Keenan. The Works of Mercy: The Heart of Catholicism. Rowman and Littlefield Publishers, 2007.
2. 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