Care with Compassion

The new entrants to the medical profession need to be encouraged to develop in them values of humanism, warmth, comfort and empathy instead of adopting a merely clinical, emotionally detached attitude towards their patients
By Dr Suneela Garg

Today, stakeholders including patients and employers find that skills pertaining to professionalism, humanism, diversity, communication, and ethics are as important for patient care as the doctor’s ability to diagnose and treat illness. Practitioners should be able to demonstrate these skills in real time, yet they are not explicitly taught in the medical course – students are expected to learn them through observation of role models.
Some students may never witness such role modeling. Research suggests that the creative instincts of medical students could be utilized through exposure to the humanities to explicitly develop these skills. Medical educators worldwide are examining newer ways to actively train and assess learners in professionalism and related competencies.
Using Rudyard Kipling’s “Five Ws and One H” guide to writing a scientific paper, we propose the ABCDE paradigm and demonstrate why it is most appropriate to use the medical humanities to teach professionalism and humanism.
Research suggests that the creative instincts of medical students could be utilized through exposure to the humanities to explicitly develop these skills. Medical educators worldwide are examining newer ways to actively train and assess learners in professionalism and related competencies. New entrants to the medical schools are creative and enthusiastic; however, as they advance academically, emphasis on rote learning, a stacked curriculum, and other inherent difficulties of a career in medicine result in clouding and burnout.
They start off with idealistic feelings about their role as medical care-providers; but soon altruism and social-mindedness is replaced with cynicism and self-interest. Researchers suggest that by providing opportunities through arts and humanities, the creative instincts of medical students can be utilized and honed to foster professionalism, humanism, respect for diversity, desirable change in attitude, better communication skills, and ethical behavior. These skills are not explicitly taught in the current curriculum; students are expected to imbibe them through exposure to role models.
To prescribe such a hit-or-miss method to the acquisition of competencies that are critical to holistic patient care seems inappropriate. Stakeholders, including patients and employers, find that these are the skills that they want a medical practitioner to demonstrate in real time. These are as important for patient care as the ability to competently diagnose and treat illness
Using Rudyard Kipling’s “Five Ws and One H” guide to writing a scientific paper it is appropriate to propose the ABCDE paradigm and demonstrate why it is most appropriate to bind medical humanities to professionalism and humanism.

I keep six honest serving-men
(They taught me all I knew);
Their names are What and
Why and When
And How and Where and Who.

Rudyard Kipling,
The Elephant’s Child, 1902

What is the ABCDE paradigm?
Appropriate Analytical Attitude, Ethical & Professional Behaviour, Effective Verbal and Non Verbal Communication, Respect for clients, Empathy not Sympathy within these broad competencies educationists must be charged with actively training for the acquisition of ethical and professional behavior.
Communication is an art and a vital skill since medical students are expected to communicate, orally and in writing, with patients and their relatives, with members of the health team, and with peers.. Opportunities should be created for learners to practice communication skills outside the routine course where communication is only attended to in passing.
India is a land of Diversity – not only in terms of language, economy, caste and culture, but also from the standpoint of abilities. To communicate efficiently and treat effectively, medical students must appreciate and respect these differences. Respecting beliefs that are contrary to one’s own may help foster the therapeutic relationship. Doctors could tailor care to make it inclusive and socially relevant, thereby helping to reduce health inequities and improve health outcomes of marginalized groups and under-served communities. It is important for doctors to be culturally competent; a case in point is the relative ‘blindness’ of the medical community to people with disabilities and transgenders.
Finally, Empathy is the ability to put oneself in the patient’s shoes; of being moved by the patient’s story. Unfortunately, medicine also teaches detachment so that informed, unemotional patient-care decisions can be made. Doctors often find themselves torn between detachment and empathy; for some, detachment wins to the patient’s disadvantage. A detached empathy is perhaps desirable, one in which the doctor’s attention is on the patient but where the mind is not distracted by sharing the patient’s emotions. The doctor can focus on body language and signs of distress while listening to the patient’s story, a strategy found to elicit more details than just questioning them impassively. Medical students should be exposed to strategies that convey empathy and improve communication.

Why use medical humanities to teach the ABCDE paradigm?

Training in the medical humanities serves to focus students’ attention on the patient as a whole and not just on the symptoms of disease. Exposure to art, films, theatre and literature on illness from the patient’s or care-giver’s perspective helps develop students’ observational and analytical skills, and hones self-reflection. Both the artist and the viewer are provoked to reflect – an example may be found in an article published earlier in this journal, where an artist who also practices medicine reflects on suffering and the helplessness of one who is sick. By providing insight into human suffering, use of media may enhance empathy, imagination, and respect for diversity. Media has also been used to make students aware of ethical aspects of medicine, their responsibilities to self, colleagues and patients, and to inculcate professionalism. Street theatre, Theatre of the Oppressed, and Forum theatre have been used as problem-solving techniques in some communities including the medical. Experiences with diverse forms of theatre have been reported earlier; we have found it a useful tool to encourage self-expression, build empathy, and explore the experience of illness.
Medical biographies are an important source of role-models; biographies of physicians can inspire students in humanizing their medical practice. Through the writing of reflections and narratives, students hone communication skills, reflective practice, empathy and professionalism
Anthropology, by exposing learners to the study of society and cultures, not only hones cultural competency, but can also be used to remind students about the ancient tradition of mentoring – from Kautilia and Chandragupta to doyens of music and dance – more accomplished ‘gurus’ have been mentoring learners for centuries, helping them develop various competencies.
The medical teaching centred around a paradigm that avoids didactic teaching, and concentrates instead on encouraging medical students to use their imagination and creativity is less likely to be found burdensome.

The challenge of preparing medical students for professional, humanistic and ethical concerns in the practice of modern medicine and in keeping with the competency, it is necessary to adhere to ABCDE in letter and spirit.

(The author is Director Professor and Head Community Medicine, Maulana Azad Medical College & Associated Hospitals, New Delhi )