Compassion in a World of Evidence-Based Medicine

We are medical doctors, psychiatrists, working in a world of infinite need, finite resources, and – increasingly – ‘evidence-based medicine’. We are trained to ask questions such as: What is the evidence behind this intervention? What are the facts? How do we know that we are helping our patients, rather than harming them?

This is a different world to that of many of our predecessors. Today, the volume of information at our fingertips continues to grow exponentially. Clinical work is evaluated by reference to service targets and key performance indicators which can appear distant from what really matters to patients and families, and what mattered to previous generations of healthcare professionals: care, compassion, and patient-doctor relationships.

Today, we treat ‘service users’ or ‘clients’, rather than patients. Doctors are ‘specialists’ who work in professional silos which are so embedded that we barely see them anymore, surrounded by professional jargon so ubiquitous that we no longer hear it, like the fish that never heard of water.

While many of our predecessors were specialists in providing person-centred care to patients and their families, healthcare professionals today – including us – tend to know more and more about less and less. To compound matters, health services are commonly delivered in settings and systems that are over-stretched, demanding, and dehumanising for patients, families, and staff. This increases alienation and distance from the human interactions that lie at the heart of all good caring.

As a result of these trends, many healthcare professionals feel chronically tired, emotionally drained, deeply heart-sore, and ultimately burnt-out, notwithstanding the moments of joy, laughter, and common purpose that medicine inevitably brings. Too often, these moments of connection, although therapeutic and magical at the time, simply highlight the uncertainties and even the darkness that surrounds them. Commonly, staff struggle to make sense of healthcare systems that seem to value neither ‘health’ nor ‘care’.

Most doctors and other healthcare professionals entered their professions in order to help others. We are expected to care, to mend, and to cure, but the systems within which we work (and which we co-create) seem to conspire against us at every turn. Sometimes, it can feel as if we are working against the system rather than with it, trying to snatch moments of good healthcare for our patients despite the way services are structured, rather than because of it.

All of this frantic effort and frustration comes at a steep cost to all, not least the professionals who feel powerless to make the high-level changes that are so clearly needed. In practice, good care often involves gaming or gently subverting the health system in some way, extracting an unexpected service for someone in desperate need, or calling in a favour from a colleague elsewhere in the system for a particularly challenging case. This is no way for health systems to operate.

Anxiety, Fear, and Disconnection

When we recall patients whom we have seen in the past, or are seeing at present, there is often a sense of fear associated with the recollection: fear of making a mistake, fear of not knowing the answer, fear of getting something wrong that will impact on the person, or fear of a complaint when there is an adverse outcome, despite our best efforts. This fear can be bedded in an atmosphere of fatigue, pushing ourselves too hard, working through lunch or other breaks, and feeling compelled to prioritise work over other activities that would contribute to our well-being and (ultimately) would also improve our work.

On this basis, many healthcare professionals – including us – give up fresh air, wholesome food, connection with others, time spent doing nothing, and time spent doing things we love such as arts, creativity, and sport. We erode our connection with nature, lose our sense of being grounded on this earth, and forget that we exist on a planet of beings who all seek to be happy and free of suffering, just like us. We become locked in hardened, habitual patterns so that our day-to-day sense of caring diminishes. People become barriers to happiness rather than the means to achieve it. This is sad and wrong.

When we were going through the early years of our postgraduate medical training as non-consultant hospital doctors (i.e., ‘residents’), it sometimes felt as if our shifts would never end. Often, each additional task was a source of anger and irritation, even though each task inevitably reflected some aspect of a human being in pain and some aspect of our efforts to help them. Too often, it did not feel that way to us. We were bedraggled, sleep-deprived, and confused.

We ask ourselves now: What would have helped us to find the joy in work at that time? What would have helped us to build the strength and resources that we so clearly needed to meet those demands in a robust, equanimous way? What would have helped us to remain whole after those long days on hospital wards, and the endless nights? What would have helped us to leave the people we had contact with the better for having come across us?

Finding Values, Solutions, and a Path Forward

Many healthcare professionals struggle with these issues: overwork, bureaucracy, loss of meaning in daily tasks. Too often, the health systems within which we work are not just challenged but overwhelmed, lacking resources, and even broken. But the people working in the system – including us – still want to be happy, fulfilled, whole people who truly help others. We want to fulfil our desires to care and to cure, and to leave the world a better place for us being in it as healthcare professionals. But how?

Perhaps the first step lies in recognising that while we do not have full control over the shape of the healthcare systems within which we work, or indeed the societies in which we live, we can control how we navigate these contexts, how we respond to them, and how we seek to be in the world. There are many things that we can control and shape, at least in part. We are not helpless. We can have an immediate impact at the level of day-to-day care and we can also take action at the level of our organisations in the longer-term.

We are more adaptable, creative, and powerful that we think. We are also kinder and wiser that we give ourselves credit for. We can do more than we imagine.

Compassion is an invaluable tool in our efforts to address these issues in healthcare. There is a reason why compassion is mentioned in medical graduate profiles, ethical guidance documents, interviews with patients, reports on health services, and everywhere that healthcare is discussed in truly human terms. Compassion is an attribute that, at its most wonderful, can leave a person feeling that they have made the world a better place. At its bare minimum, authentic compassion can leave two people involved in an interaction feeling that they have helped each other in some way.

Most of all, compassion allows us to shed the need to ‘fix’ things or each other, and focus instead on being seen and seeing each other as human beings. Ultimately, that is what we really want from each other and our world: to see and be seen.

This is especially important in the context of clinical care. Some readers might be familiar with the experience of meeting a person who went to see a healthcare professional at their most vulnerable moment and was met with apparent lack of interest and apparent lack of human feeling, while simultaneously being expected to confide personal details about their complaints. Our hearts break as we listen to these stories. On hearing such accounts, many healthcare professionals vow to provide more person-centred, heartfelt care and to try to teach the next generation of healthcare professionals about how to respond in these situations. This involves making compassionate care a day-to-day clinical reality, rather than an aspiration in ethical guidance documents. It means making compassion real.

The idea for this book came from these issues, these questions, and the consequent desire to make compassion more central to clinical care.

To summarise the book very briefly, we argue that compassion is a key value in health and social care. Our book offers a practical approach to compassion in medicine, starting with the most fundamental question of all: What is compassion? The book explores the background to compassionate healthcare, examines how compassion differs from concepts such as empathy, and outlines the close relationship between medical professionalism and compassion. The relevant research base is presented and interrogated, with particular focus on compassion in healthcare, the neuroscience of compassion, the role of resilience, and the centrality of self-compassion, which is the basis of all compassion. The emergence of compassion-based therapies is also outlined.

In Part II, the book moves on to provide practical strategies and exercises to assist healthcare workers in practising compassion by cultivating mindfulness and awareness, deepening compassion when providing care, and developing resilience for the inevitable challenges of healthcare settings. Finally, the book examines compassion at the level of healthcare organisations and looks at ways to build compassionate health systems which deliver better, more compassionate care for the benefit of all. Compassion matters deeply. This book outlines why, how, and what we can do to increase compassion in healthcare.

Part I: ‘Compassion in Healthcare’

As mentioned, we have divided this book into two parts to reflect both the concepts and evidence underpinning compassion in healthcare (Part I) and practical approaches to compassionate care on a day-to-day basis in clinical settings (Part II).

To start Part I of the book, Chapter 1 asks: ‘What Is Compassion?’ Compassion can be difficult to define in words, but most people recognise compassion when they experience it. At its heart, compassion is the feeling of being motivated to act in the presence of suffering. From a psychological perspective, the construct is conceived as having two dimensions: state and trait. The compassionate state reflects the feeling of compassion or having a compassionate response in the moment. A compassionate trait is more stable, reflecting a general tendency towards compassion or towards feeling and responding compassionately most of the time. For people who are expected or required to be compassionate in their everyday life or work, compassion requires sustained courage and a continued willingness to engage with suffering, rather than avoid it. This can prove challenging, but it is deeply worthwhile and is essential in medicine.

Chapter 1 explores compassion from psychological, evolutionary, and physiological viewpoints. Despite a useful and growing literature in this area, a precise definition of compassion in practice can remain elusive. The meaning of compassion is not written in stone; it flows. As a result, what the concept means in healthcare, and how it works in practice, are, perhaps, made most tangible through providing compassionate care to patients, interacting with families, discussing compassion with colleagues, and teaching students about compassionate healthcare. Definitions are useful, but they need to settle, shift, and evolve over time. If compassion is defined flexibly and understood wisely, it can shape care in positive ways, improve outcomes, and change lives. This chapter explores the conceptual background to these issues.

Chapter 2 moves on to explore the ‘Background to Compassionate Healthcare’ in more detail. In theory, compassion lies at the heart of all healthcare. There are, however, many reasons for the erosion of compassion in day-to-day clinical practice: increased demand on services, limited resources, large caseloads, insufficient time to spend with each patient, and a consequent transactional rather than relational approach to each person. Systemic focus on efficiency and throughput can also impede the cultivation of compassion, empathy, understanding, and addressing the individual needs and concerns of each patient and their family. Growing reliance on technology and electronic health records can further depersonalise patient interactions and reduce compassion, despite the many benefits of such technologies in practice.

Chapter 2 outlines these and other factors which tend to diminish compassion, reflects on the relevance of overarching values in medical education, focuses especially on the meaning of ‘equanimity’ in this context, and overviews the place accorded to compassion in guides to professional ethics and codes of practice. The role of health systems in limiting compassion and empathy is balanced by evidence supporting the importance and possibilities of compassionate care, especially during times of emergency such as the Covid-19 pandemic in the early 2020s. This pandemic brought renewed focus to compassion during a public health crisis, highlighted the need for sustained compassion in the delivery of care, and underlined the need for self-compassion among healthcare workers at a time of significant risk and uncertainty.

Chapter 3 looks at ‘What Compassion Is Not’, noting that the literature about values in healthcare contains many terms which are sometimes used interchangeably. These terms include ‘compassion’, ‘sympathy’, ‘empathy’, ‘kindness’, ‘communication skills’, and various other words which are intended to denote a caring, understanding attitude towards healthcare provision. Confusion between these terms adds significantly to the apparent heterogeneity of research in this area and raises the worrying possibility that some writing on this topic uses these terms interchangeably. We try our best to clarify these matters for readers in this chapter.

The chapter starts by exploring specific terms which are often used as synonyms for ‘compassion’, such as ‘sympathy’, ‘empathy’, ‘kindness’, and ‘communication skills’, and then focuses on two of the so-called ‘near enemies’ of compassion: pity and ‘horrified anxiety’. We might try to cultivate compassion, but, at times, emotions can arise that may be mistaken for compassion and can have negative effects. Clarity about these concepts and terms can help to understand their significance, their importance in healthcare provision, and the ways in which they can support, as well as differ from, compassion. Overall, this chapter echoes the main arguments of the book by emphasising that compassionate healthcare requires an all-of-system approach, rather than isolated changes, paper exercises, or tinkering around the edges. Reflecting on terminology can help greatly in this process.

Chapter 4 examines the relationship between ‘Medical Professionalism and Compassion’. This chapter starts by setting out the formal relationship between medical professionalism and compassion, looking at codes of ethics and practice guidelines, chiefly for medical professionals but also with reference to other healthcare workers. The chapter explores the importance accorded to compassion in ethical guidance for doctors in the United Kingdom (UK), Ireland, the United States of America (USA), Australia, and New Zealand. It then examines guidance specifically aimed at psychiatrists, including documents published by the Royal College of Psychiatrists in the UK, the College of Psychiatrists of Ireland, and the American Psychiatric Association in the USA.

Many of these codes of ethics and practice guidelines emphasise the importance of compassion and related values, with the Royal College of Psychiatrists providing particularly detailed suggestions about building and sustaining compassion in mental healthcare. Compassion and related values also feature commonly in codes of practice and ethical guidance for other clinical professionals, such as nurses, midwives, social workers, occupational therapists, and others. This chapter concludes that, taken together, these statements of practice values and ethical principles reflect a welcome and growing emphasis on compassion in guidance for healthcare professionals across many clinical domains.

Chapter 5 returns to the key theme of ‘Compassion in Healthcare’. This chapter notes that, despite its expanding presence in codes of practice and ethical guidance for healthcare professionals, there is limited research into the precise components of compassion in clinical settings. This chapter continues the book’s exploration of compassion in healthcare by noting occasional confusion surrounding the term ‘compassion’, and the distress that an absence of compassion can cause for patients, families, and staff. What, precisely, does compassionate healthcare mean to patients and healthcare providers? What does it look like in practice?

This chapter examines research that seeks to define compassionate healthcare and tries to delineate its constituent elements. Evidence to date suggests that patients experience compassionate care when their healthcare providers are emotionally present, communicate effectively, enter into their experience, and display understanding and kindness. Listening and paying close attention are the most dominant features of compassionate care, along with following‐up and running tests, continuity, holistic care, and respecting preferences. Other relevant factors among healthcare providers include honesty and kindness, as well as specific behaviours, such as smiling.

Chapter 5, then, outlines and references research supporting simple ways to demonstrate the compassion that healthcare workers routinely feel but sometimes do not convey clearly to our patients, owing to challenging circumstances. The chapter concludes with considerations of cultural and ethnic factors relating to compassion, as well as the importance of engagement, mindful awareness, and emotional intelligence in generating and deepening compassionate practice in healthcare.

Chapter 6 explores the expanding field of research into ‘Neuroscience and Compassion’. A growing literature examines the relationship between compassion and various aspects of nervous system function, especially the brain. This chapter explores this field and seeks to place emerging research findings in a broader context. The chapter starts by outlining neuroimaging studies of compassion and then examines the topic of empathy and the brain, noting evidence that observing another person’s emotional state activates parts of the neuronal network that are also involved in processing that same state in oneself. This is followed by further discussion of evidence about the neuroscience of compassion and, especially, the effects of compassion training.

This chapter notes that research suggests that multiple areas within the brain are involved in compassion and compassion training, with some regions more strongly implicated than others. Against this background, relevant conclusions are presented and potential directions for future work outlined. Overall, research into the neuroscience of compassion supports the idea that compassion can be cultivated deliberately through training. There is evidence that activities such as compassion training and meditation can increase positive affect, boost resilience, facilitate altruistic behaviour, and possibly even assist with equanimity. These ideas are underpinned by growing neuroscientific evidence of impact on the brain. These valuable findings underscore the importance of developing compassion as a skill and fundamental attribute for healthcare workers across all settings.

Chapter 7 examines the relationship between ‘Resilience and Compassion’, starting with the relevance of resilience in healthcare, especially during the Covid-19 pandemic of the early 2020s. This chapter notes that while a certain amount of resilience is helpful and even essential, resilience depends on not only the personal characteristics of each healthcare worker, but also the conditions in which they work. Relevant factors include the structure and function of teams, models of organisation, quality of leadership, and provision of resources. These matters have an enormous influence on individual experiences, attitudes, and behaviour, and on the levels of resilience that are required and accessible in the workplace, as well as compassion.

This chapter also considers the concepts of ‘compassion fatigue’ and ‘burnout’, and outlines barriers to, and facilitators of, compassionate care. Systemic challenges can include competing system demands and time constraints, in addition to inadequate resources, communication issues, poor emotional connections with the broader healthcare system, and the perception and/or reality of staff not being valued for the care that they provide. These are themes that will likely resonate with many people who work in large healthcare systems where organisational challenges can loom large, often distracting focus from day-to-day patient care. The chapter concludes by examining the roles of mindfulness and meditation in navigating some of the challenges outlined.

Chapter 8 is devoted to ‘Self-Compassion’, which is the ultimate basis of all compassion. This chapter explores the concept of self-compassion, the idea of moral injury, and ways of navigating complex healthcare roles with self-awareness, kindness, and greater compassion for all. Self-compassion refers to the ability to act in a compassionate way towards ourselves when we are suffering. It involves recognising our suffering, being moved by it, and offering kindness and understanding towards ourselves. Human beings can be our own worst enemies and toughest critics. Cultivating self-compassion helps to address this tendency, increase resilience, and empower us to show greater compassion towards others.

This chapter also examines ‘moral injury’, which stems from situations in which a person has to make choices that go against their core values and can corrode compassion. There are many varieties of moral injury, ranging from a single, large, conflictual decision to a sustained pattern of smaller but still conflictual decisions that arise on a day-to-day basis. The latter is common in large healthcare systems owing to rapid decision-making, inadequate resources, outsized expectations of healthcare providers, and working conditions that are often not conducive to clear thought: long hours, sleep deprivation, inadequate personal support, and a lack of compassion for staff. This chapter examines how to manage the risk of moral injury in these situations, how to boost self-care for staff, and the importance of self-compassion when managing or living with difficult experiences and situations, especially on a recurring basis.

Chapter 9 focuses on ‘Compassion-Based Therapies’. One of the key features of compassion is that while compassion does not necessarily change the difficult situations and experiences that occur in life, compassion helps us to face these challenges in a more balanced way, navigate their complexities, and maintain an attitude of kindness. Certain skills support this approach and help us to develop and sustain compassion even in circumstances that are far from ideal. We are more adaptable and stronger than we think, once we can access the resources that already lie within ourselves and within each other.

Against this background, recent decades have seen a remarkable growth of research in this field. There is an especially welcome flourishing in the area of compassion studies and compassion-based therapies, which form the focus of this chapter. Paul Gilbert, in particular, has developed compassion focused therapy (CFT) which is outlined further by the Compassionate Mind Foundation and available in many countries around the world, as well as online. The Compassionate Mind Foundation advances an evolutionary and bio-psycho-social informed approach to compassion, and this forms the basis of CFT and ‘Compassionate Mind Training’.

Chapter 9 starts by exploring the origins of CFT and key attributes for the cultivation of compassion, before considering compassion and shame in clinical contexts. Shame can be an especially powerful emotion with a profound effect on health-related behaviour. Compassion can be a valuable way to address this issue. This chapter examines CFT in practice and notes the growing evidence base to support its use, with appropriate referencing. The chapter concludes with further reflections on compassion and self-compassion as key skills and vital resources in healthcare settings.

Part II: ‘Practising Compassion’

Having considered ‘Compassion in Healthcare’ in Part I, Part II of this book presents practical steps towards operating from a place of safe, secure grounding to become more compassionate towards ourselves and others when confronted with suffering.

Chapter 10 focuses on ‘Cultivating Mindfulness and Awareness’. Awareness is the quality of knowing and understanding that something is happening or exists. It means bringing conscious attention to whatever is arising, with as little judgement as possible. On a subconscious level, we respond to what is happening in the moment by applying existing information in our brains to the external event. This response is often habitual or unaware, as we tread well-worn grooves in our minds and follow heuristics which help us to manage the vast amount of information that comes our way every moment. These cognitive shortcuts can be helpful, but they can limit our understanding, undermine our confidence for navigating new situations, and diminish our attention to what our bodies and minds tell us in the moment.

This chapter argues that deepening awareness involves developing mindfulness, which means paying careful attention to the present moment, simply and directly, rather than being distracted by thoughts, judgements, or interpretations. Traditionally, there are four components or foundations of mindfulness. This framework allows us to develop awareness of all aspects of our experience. These are: (a) mindfulness of the body; (b) mindfulness of feelings or feeling-tone; (c) mindfulness of states of mind or emotions; and (d) mindfulness of thoughts. This chapter explores these various forms of mindfulness and offers exercises and guidance for developing greater awareness and mindfulness in day-to-day life.

Chapter 11 is devoted to ‘Deepening Compassion’. As we cultivate mindfulness, we can develop and deepen our compassion skills, both for ourselves and for others. Without self-compassion, we will struggle to look after other people compassionately. This chapter explores ways to build self-compassion and how to extend this compassion to other people in our lives. This includes our patients, their families, and our colleagues, as well as our own families and circles of friends. These are important tasks that find their roots in the theoretical and research foundations of compassion, and build on the awareness skills that we develop through mindfulness practice.

Against this background, Chapter 11 presents exercises for deepening self-compassion, growing compassion for other people in our lives, and extending that compassion to everyone. By focusing on common humanity, we move towards a more stable, engaged response to other people, less informed by our own situation and more informed by theirs, less shaped by our judgements about them and more shaped by what we can achieve together. Developing compassion for everyone can be challenging, especially for people whom we anticipate will be difficult, but, with awareness, we can move in the right direction. This chapter concludes with an exercise that focuses on generating feelings of compassion towards other people by encouraging mindfulness of our connection with all beings and the planet as a whole.

Chapter 12 focuses on ‘Developing Resilience’. This chapter looks at ways of building personal resilience as a foundation for compassion. The chapter starts by presenting relevant learnings about resilience from the Covid-19 pandemic; outlines positive behaviours that promote individual physical health, mental health, and resilience; presents a guided imaginative practice focusing on resilience and inner solidity; and, finally, draws together key themes of resilience, equanimity, and compassion towards the end of the chapter.

The overall message is that self-care is (a) an act of radical self-compassion, (b) the basis of compassion for other people, and (c) a vital foundation for resilience, among other qualities. We cannot care for others, or become more resilient, unless we care for ourselves, so it is essential that healthcare workers pay attention to their physical and mental health. This means optimising levels of physical exercise, sleep patterns, and dietary habits, as best as possible. It also includes specific steps to improve mental health, both in our own lives and in relationship with other people. Physical and mental health are intimately related with each other. Both are vital foundations for learning greater resilience and cultivating deeper compassion for ourselves, our patients, their families, and our colleagues in the healthcare professions.

Chapter 13 looks at ‘Building Compassionate Health Systems’. This chapter focuses on systemic factors in healthcare systems and how these can promote qualities such as mindfulness, awareness, resilience, and compassion. Too often, health systems do not promote these values at the organisational level despite the best efforts of individual healthcare workers. With attention and awareness, however, this can be remedied. This chapter examines the themes of compassionate leadership in healthcare organisations, resilience in these settings, and specific approaches that healthcare professionals can take to increase compassion across the healthcare systems in which we work.

Key steps outlined in this chapter include: (a) leading by example to promote compassionate behaviour for better care; (b) supporting the well-being of colleagues and staff we manage; (c) fostering open communication across clinical and managerial teams; (d) including patients and families in decision-making and valuing their perspectives; (e) promoting teamwork and collaboration that are inclusive, adaptive, and resilient; (f) recognising and rewarding compassionate care, both formally and informally; and (g) making self-compassion a key organisational value: healthcare is challenging, we are all human, and self-compassion is the basis of compassion for others.

The final chapter of this book presents ‘Conclusions: Compassionate Healthcare’. This chapter notes that the purpose of the Handbook of Compassion in Healthcare: A Practical Approach is to help make compassionate care a day-to-day clinical reality for everyone: patients, families, and healthcare professionals. We do not suggest that current health systems are entirely lacking in compassion. All around the world, clinical care is provided by staff who seek to be professional, compassionate, and patient-centred at all times. The very existence of health centres, doctors’ surgeries, outpatient clinics, acute hospitals, daycare centres, dental practices, physiotherapy centres, and many other healthcare facilities is a testament to basic human compassion, to society’s commitment to help the afflicted, and to our fundamental desire to support each other in times of difficulty. We care. Deeply and urgently, we care.

At the same time, it is clear that healthcare settings vary widely in relation to compassion, with some services already excelling in compassionate care, but others in need of a more conscious or sustained focus on compassion. Many services do well, but most could do better. Improvement is always possible. Health systems are operated by people, for people. At all times, compassion matters deeply.

With this in mind, compassion can be the value that improves health services on the ground, enhances their tone and function, and optimises outcomes for patients and their families. Compassion can make our fundamental caring impulses more apparent, more effective, and more human. Compassion helps us to connect better and more.

Always and everywhere, compassion matters.