Reopening the Eyes of Compassion

I vividly remember my first day as an intern at a large inner-city hospital in Southern Africa. As I made my morning rounds through the male cardiothoracic unit, I saw patient after patient emaciated from esophageal cancer that had clawed its way into the body beyond any hope of cure. Each man begged me for relief from the pain that seared his chest, burning through his spirit. I felt helpless -- even ashamed. Six years of medical school had not prepared me for anything like this. I had no idea that my training in the art of medicine was just beginning.

My first realization was that none of my patients expected a miraculous cure. Most of them had traveled hundreds of miles across the dusty back roads of Africa simply hoping to find relief from their physical suffering and to die in peace. Once I realized this, it freed me from the illusion of omnipotence conferred by my new white coat. Suddenly, my task seemed obvious. In chart after chart I wrote the orders: "Morphine every four hours, titrated up as necessary to control the patient's pain." But it was not that simple.

Over the next few days my patients' furrowed faces still framed their despair -- because they had not received their medications! At first, I assumed the problem was an administrative error, but several conversations with the nursing staff proved me wrong. The nurses were ignoring their patients' distress -- and my medication orders. I angrily confronted them, challenging their professionalism and their humanity. Nothing changed. As my hostility toward the nurses escalated, their contempt for me deepened. Then the nurse administrator, Matron Mutetwa, summoned me to her office. "You need to stop harassing my nurses," she said. "It is not fair. Young doctor, you need to understand these people are invisible to us. They are not from our tribe, we cannot see them!"

I left her office, still angry, but I stopped challenging the nurses. On daily rounds I administered the morphine myself as best I could, but part of me was frozen. It took me more than 20 years to fully understand that my experience in Africa was not simply a "Third World phenomenon." These dying patients and Matron Mutetwa had ushered me through the portals of suffering and into compassion.

Our Own Culture of Pain
The statistics in our country speak for themselves: 50 percent of hospitalized patients and 80 percent of nursing-home patients report undertreated pain; 25 percent of nursing-home patients suffering from cancer and experiencing severe pain receive no analgesia whatsoever. A recent study found that only one in five patients reports that they receive adequate pain relief when they visit their outpatient physician. Disturbed by these and other research findings, the State of California has recently introduced legislation requiring that physicians receive mandatory education in pain management. Unfortunately, the research data also indicate that these conventional educational approaches produce very little improvement in patients' pain management. The doctors and nurses receive the information they need to manage pain, yet the patients continue to be in pain. Why?

Some claim that our current doctors are insensitive because they were recruited into medical school on the basis of their science smarts rather than their people skills, but the reality is quite different. Research has shown that students entering medical school score higher than their peers on scales of empathy and altruism. Unfortunately, recent research has also found that empathy diminishes as these students progress through their medical training! In other words, our professional caregivers are not hard-hearted people; instead, our doctors and nurses are the victims of a system that makes it almost impossible for them to manifest their natural impulse to be compassionate healers.

Sometimes it really does seem as though we create different tribes -- the tribe of the omnipotent "white coats" and the tribe of voiceless "Johnny-smocks," each inhabiting vastly different worlds, each blind to the other's humanity. We can't solve this crisis by focusing on the knowledge base of our clinicians. Instead, we need to actively address the "disheartening" social structures of our hospitals, medical schools, nursing homes, and clinics. We need to be able to see each other again.

Building Empathic Accuracy
While neuroscientists have been working to understand the brain mechanisms involved in empathy (see box at bottom,"The Neuroscience of Compassion"), social psychologists have made important discoveries about the social factors that support or impede our ability to perceive another person's emotional state, known as empathic accuracy. Certain social factors have been found to strongly support our empathic accuracy for one another. These include:

• No physical power differential between the parties (i.e., parties communicate at eye level).
• No social power differential between the parties (i.e., neither party has control over the other).
• The expectation of a long-term relationship.
• The expectation of a favorable outcome for the relationship.
• Both parties are physically responsive and reinforce one another's nonverbal communication (i.e., smiling, making physical contact, etc.).

Based on this list, if one were to predict the best environment for supporting empathic accuracy, it would be a first date! We all can remember the powerful alchemy we experienced on our first date with someone special.

However, if one were to construct a social environment designed to inhibit empathy, ironically, it would look like a modern hospital. Straitjacketed by their white coats, doctors and nurses are taught to display little emotion -- while their patients lie immobile and often humiliated by having to wear a paper "Johnny." Patients typically feel overwhelmed by the hospital environment and retreat into silent submission for fear of alienating the all-powerful medical team. Harnessed by third-party payers and hemmed in by their subspecialties, doctors and nurses seldom expect to see their patients beyond their current interaction and are always wary of a potential malpractice suit that may haunt them for years. Patients who are seriously ill or dying lie quietly in the shadows of their diagnoses, too incapacitated to elicit any compassion in their caregivers. Doctors and nurses fail to respond to their patients' pain and suffering because we have created a health-care system that makes empathic communion almost impossible.

This is not surprising. We have built our health-care system as a shrine to science, not compassion. The solution therefore does not lie in scientific breakthroughs or a more detailed understanding of pain physiology and pharmacology. Through her own bias, Matron Mutetwa pointed the way: we need to recognize each other as fellow tribe members and create healing environments that support, rather than block, our natural capacity for empathy and compassionate response.