Compassion

Compassion is the quality or virtue of an individual to feel for someone else a strong sense of consideration for his/her despairing situation.

The two-year-old girl was resting peacefully in the critical care unit of a Southern, well-staffed, medium-sized surgical specialty hospital. She had received multiple blood transfusions after severe splenic traumatic injury that required surgical intervention with spleen removal due to uncontrollable hemorrhage. Physically, everything looked fine up to this point. However, the surgeon, Phil Castellar, a middle-aged, abrupt, and unmannered professional, had previously indicated to father and mother that Rosie Mercado, the patient, would not require any organ extraction and that the surgery was for exploratory purposes only. He had gone on to say that the spleen should not be removed under any circumstances, especially in young children, because the procedure could make the patient more susceptible to infections. Mr. Mercado and his wife, Annie, were well aware of the state of affairs. They even remembered the doctor's exact words: “Do not let anyone touch the spleen. It will be tragic!”

When he finished this case, Brutus Phil, as he was sarcastically referred to by his detractors, directed himself to the waiting room and spent less than two minutes with the family, to whom he gave this final response: “The spleen is out and she has to live without it.” He then abruptly left the room with virtually no opportunity for discussion and even less consideration for the worried parents. The anxious father and mother attempted to reach the surgical specialist, but he would not return their calls. Nurses in the unit attempted to pacify the irritated family as they eagerly awaited an answer from the operating surgeon, but no one could reach him. He could not be found!

Late the following morning, Dr. Castellar appeared before the caring parents with an unwarranted feisty attitude. Immediately upon his arrival, he indicated, “I do not like to be called for matters that are not important. You do not have the right to disturb me for emotional reasons. Now, what was the problem?” Mr. and Mrs. Mercado could not believe this unexpected and inappropriate response. They composed themselves and said, “Doctor, we were trying to talk to you about the situation with our little Rosie. You left without giving us all the details of her case, and we were very concerned about her condition.” The experienced trauma and general surgeon did not know how to respond since he had just seen Rosie, and she looked amazingly well. “She is fine,” he said in a tone of voice that clearly left no room for discussion. “But what about the spleen?” Mr. Mercado added. “You mentioned that no one should remove the spleen because it would be tragic.” Even though the doctor recognized these as his exact words, he could not accept the burden of inappropriate behavior. “Who cares about the spleen now? She is alive, isn't she?” the frustrated surgeon responded. “With all my respect, doctor, our concern is with our little girl and what will happen to her in the future,” said the quiet Annie Mercado, attempting to hold the surgeon's attention and obtain a satisfactory answer. Dr. Castellar could no longer contain himself and immediately stood up. Irritated for no reason with the whole event, he exclaimed, “We are not understanding each other. We are wasting our time discussing this matter. You need to talk to the pediatrician for future visits and follow-up.” He then stomped off and demanded the nurse supervisor reach the pediatrician on call for follow-up and discharge.

Everyone in the nursing station immediately recognized the compassionless behavior of the knowledgeable and skilled trauma specialist. It was evident in the minds of the hospital administrators and physician educators that something had to be done with Dr. Castellar. Meanwhile, the Mercados could not comprehend the attitude of the famed surgeon or his failure to understand their concerns.

In as much as this case was not entirely real, the problem of lack of empathy and compassion within the medical community can at times be extraordinarily clear. The need for compassion in this realm is too important to let pass without formal acknowledgement and clear recognition by medical professionals (physicians, surgeons, and administrative officials). But beyond acknowledgement and recognition, what can be done to prepare medical professionals to appropriately deal with the despair of the sick and dying?

The question and well-defined challenge is how to educate students, surgical residents, and faculty regarding the exposure and specific development of professionalism and, in this particular circumstance, compassion in surgery [[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]]. This is no easy task, since many generations of surgeons before us have frequently approached the practice of surgery without emphasizing compassion as an important element of the healing surgical art. Surgeons past and present alike, as part of their training and their evolutionary process, as part of their mystique and the making of the professional, have not usually utilized compassion as one of the main components of the surgical career. Surgeons worry about learning the scientific basis of surgery, as well as mastering the surgical techniques needed to treat diseases surgically. And this is good, expected, and highly desirable. But in general, surgeons have not concentrated on exalting the value of compassion in their training or their surgical practice. This needs to change!

Surgeons need to find, exalt, and exude compassion in their professional practice. Surgeons should undergo theoretical and practical training not only in the science and techniques of surgery but also in the practice of compassion. Surgeons should enhance their ability to understand the suffering of others as well as the desire to do something about it [[3]]. This is the real test on the value of compassion. Surgeons need to become deeply aware of the strength of sympathy in relating to those who suffer [[3]]. Surgeons need to realize their own sorrow when faced with the despair of others [[2]]. Surgeons need to be agents of compassion as well as agents of cure.

History has not always demonstrated a positive influence on the use of compassion in surgery [[8]]. In fact, everything goes back to the management of pain, which has always been considered an acceptable companion to surgery. Even in the early nineteenth century, the great American physician Benjamin Rush (1746–1813) recommended heroic doses of painful remedies based on the belief that pain could cure [[8]]. In this atmosphere, there was no room for compassion. In the first century AD, Aulus Cornelius Celsus (3–64) defined the character of the surgeon in the following way: “Now a surgeon should be … filled with pity, so that he wishes to cure his patient, yet is not moved by his cries, to go too fast, or cut less than is necessary; but he does everything just as if the cries of pain cause him no emotion” [[8]]. This attitude pervaded surgery for a long time. Martin Pernick, in his well-researched book, A Calculus of Suffering [[8]], clearly outlined the role of the surgeon in regards to pain: “For many early-nineteenth-century surgical students, learning to inflict pain according to these dicta of Celsus constituted the single hardest part of their professional training. Benjamin Rush's student Philip Syng Physick (1768–1837), the first American to gain prominence as a full-time surgeon, became so sick at his initial amputation that he had to be carried from the room in mid-operation.” A British doctor recalled one of his earliest surgical experiences [[8]]: “As the operation, which was necessarily a lengthy and slow one, proceeded, her cries became more and more terrible; first one and then another student fainted, and ultimately all but a determined few had left the theatre unable to stand the distressing scene.” With this kind of information coming from the annals of surgical history, compassion did not yet have a proper place.

The introduction of ether anesthesia in 1846 began to change the attitudes and minds of practicing physicians and surgeons. James Y. Simpson (1811–1870), the Edinburgh physician and the discoverer of chloroform, in 1847 indicated that “the proud mission of the physician was distinctly two-fold, namely to alleviate human suffering as well as preserve human life” [[8]]. Slow but progressive acceptance of pain control was beginning to take root within common surgical practice. Compassion was part of this movement. Years later, the famed literary figure T. S. Elliot (1888–1965) introduced the sentimental romanticism of his art into the expression of compassion in the healer's profession [[8]]. He composed the following ode to compassion and life:

SHARP COMPASSION: THE SUPREMACY OF LIFE

The wounded surgeon plies his steel

That questions the distempered part;

Beneath the bleeding hands we feel

The sharp compassion of the healer's art.

However, quite different from a literary understanding of its necessity in medical practice is the practical aspect of teaching and practicing compassion. How can we establish an educational program on compassion that will be helpful in the training of surgeons? How can we develop standardized ways to teach young colleagues the importance of compassion in the routine practice of surgery? Undoubtedly, virtues of this magnitude are not simple to teach. In this case, I would call compassion—from the Latin compati (to suffer with another)—a virtue and not a skill, since virtue is “the readiness or disposition of man's powers directing them to some goodness of act” [[5]]. Virtue is doing “what is right and not what is wrong” [[4]]. And in these terms, then, compassion applies directly to being a virtue of the highest order. It is the virtue of supporting somebody in need, somebody in despair, the virtue of sympathizing and assisting others in distress.

Compassion can be taught in the classroom, on the floor, in the clinic, in the operating room, and throughout the entire surgical and clinical enterprise. Compassion can be taught by exemplifying and demonstrating the qualities associated with its practice. Compassion should be, and needs to be, part of the surgeon's daily clinical experience. Compassion should be an intricate part of the surgeon's world.

In regards to a specific teaching plan, the faculty should first be taught to identify three phases of compassion: recognition, acceptance, and participation. These phases are to be carefully considered and exemplified in practice for everyone to understand and later on to teach. In the Medicine of Compassion, Karen and Simon Fox analyzed the core skills needed to understand and review the compassion response [[14]]. Their interesting book and well-produced video are extremely helpful aids in the commitment to the teaching of this virtue. In this curriculum, they introduced four elements of compassion: acknowledgement, affection, acceptance, and attention. I prefer the initial three phases, even though either way is appropriate. Once the faculty has been assimilated into this process, residents and students should follow the same path. Specific examples from the floor, operating room, and classroom will compliment the knowledge and acceptance of compassion. Finally, weekly presentations and examinations will complete the full circle of teaching compassion.

A good example of the value of compassion in surgical practice was extremely well represented in a recent movie, The Doctor. In it, Oscar winning actor William Hurt characterized Jack McKee, the thoracic and cardiovascular surgeon who was a superb technician but a professional without compassion, a professional who believed that the surgeon's job was “to cut.” He was a professional who relied more on the prowess of the knife than on the expression of the heart, a professional who had no sensitivity toward the care of the human being. As Dr. McKee put it, “I'd rather cut straight and care less.”

But one event transformed everything! Jack McKee was diagnosed with cancer of the larynx, and the doctor became the patient. His experience in the diagnosis and management of the disease was so real and devastating to his human self, that he realized the worth of understanding and knowing the real individual behind the patient, the importance of offering empathy for someone else's suffering, the significance of caring for the impaired soul. For the first time in his life, Jack McKee realized the value of compassion.

As Jack McKee the patient developed a close friendship with June, a patient with an incurable brain tumor, he could not understand her strength in tolerating the effects of her disease. On one occasion of sincere empathetic feeling, he asked her, “Do you pray, June? Is that what keeps you together?” June very bravely responded by saying, “I pray and meditate, I eat chocolate, I go dancing.” What an incredible moment of soul opening and complete acceptance of her place on earth, what a moment of conversion for the unemotional doctor, what a moment of integration of life, hope, and suffering, what a special moment of truth, reality, and love. Even though June died a few days later, Jack McKee, the previously callous doctor, had already changed his life, had already accepted compassion as the main ingredient of caring for another human being, had already become a real surgeon! It is in this sense that this overwhelming story is extraordinarily unique for its impact on the practice of surgery today.

It is ironic to think that the advice doctors and surgeons once received of “not getting emotionally involved with our patients” is exactly the opposite of what we are so rightly being recommended to practice today. It is as if somebody is saying, “Be a good surgeon, be a good technician, and above all, be a kind and generous human being. Be a compassionate surgeon.”