Finding Meaning in Medicine

Before he had completed medical training, David Shlim found compassion slipping.  “Halfway through my first year of residency I found myself wishing that a patient would die so that I could go back to sleep,” he writes in his book, Medicine & Compassion. He had been awake and on call for 22 hours straight, and was just stealing some rest when the patient arrived in the emergency room. He shook off the thought, took care of his patient, and fell back into bed. But that early lapse haunted him.

In 1983, after years of working in a family clinic and an emergency room, Shlim again felt on the edge of serious burnout. An avid mountaineer, he moved to Nepal, where he took up practice at a medical clinic for travelers. Then he began volunteering at a local monastery, offering medical care to Tibetan Buddhist monks. He was so impressed by one of the monks, whose patience and kindness toward others never wavered, that he began to wonder how he himself could cultivate those qualities. He started to train more seriously in meditation.

“Over time, I became aware that my encounters with patients were changing in positive ways,” he recounts in his book. “I was able to create an environment that allowed patients to more easily say what they needed to say. I found I had more patience for irritable and angry people. I could help comfort severely ill or dying patients more easily. In other words, I had found a way to train in being the kind of doctor I had always wanted to be.”

In 2000, Shlim and the Buddhist abbot who inspired him, Chokyi Nyima Rinpoche, began to organize training groups for other physicians and health care professionals who wanted to be more compassionate in their work. In July of 2005, the two taught a course at the Harvard School of Public Health. These days Shlim gives talks on the subject in hospitals and other medical settings near his home in Jackson Hole, Wyoming, and is looking for ways to extend this program to other places.

Shlim is quick to point out that it isn’t necessary to become Buddhist or practice meditation in order to benefit from this approach. “It’s an internal change,” said Shlim. “And it doesn’t actually require more time. You just have to convey compassion when you walk in the room.”

David Shlim’s program is part of a growing trend around the country, intended to reconnect physicians with the human dimension of their work. From California to Wyoming to Washington, D.C., these programs are helping more doctors experience the kind of transformation that Shlim had in Nepal. They range from support groups for medical students to classes in empathy for practicing physicians. All are aimed at rebalancing a medical culture that often defines itself by technique and efficiency.

“If you were to design a compassionate health care system, you wouldn’t design it like this,” said Shlim. Often doctors settle for a kind of “de facto compassion,” he said. “‘Of course I care for you—I’m caring for you, aren’t I?’”

The problems boil down to an often rushed atmosphere and a diminished relationship between doctors and their patients. Overwhelming caseloads of patients and demands from insurance companies to limit costs contribute to the problem. While technological advances have brought enormous advantages to medical care, they’ve also given rise to the model of the objective technician, the efficient expert bent on diagnosing an illness and fixing it.

“The technician views someone as, ‘You are a broken liver and I am a liver expert,’” said Charles Garfield, a clinical professor of psychology at the University of California, San Francisco, School of Medicine. “It’s a splendid model for automobiles, but not so splendid for human beings.”

Statistics on physician burnout have soared in the past few decades. Yet this crisis in care, for patients and doctors alike, has led David Shlim and numerous other physicians to seek ways to reconcile modern medicine with more traditional values. In the process, they’ve come up with innovative programs to rekindle compassion.

Helping the patient, healing the healer

A pioneer in this field is Rachel Naomi Remen, a clinical professor of family and community medicine at the University of California, San Francisco, School of Medicine.

For the past 14 years, Remen has taught a course at UCSF called “The Healer’s Art,” in which medical students learn how to offer stronger emotional support to their patients, their colleagues, and themselves.

The course encourages students to discuss their emotions openly, appreciate the importance of listening to other people’s stories, and find ways to maintain their humanity in the often intense and impersonal medical world.

“There’s an absolute hunger for this kind of connection,” said Remen. As evidence, “The Healer’s Art” has spread to 47 medical schools, including institutions in Slovenia, Israel, and Sri Lanka.

Emma Samelson-Jones took the course in her first year of medical school at UCSF. “I came away with the sense that medicine is more than finding the correct diagnosis and treating that condition,” she said. “Being present for somebody may be more valuable than all the science we are learning.”

As part of the class, she and other students wrote their own versions of the Hippocratic oath. (See sidebar.) Samelson-Jones’s oath read:

Do not ask me what is wrong, for I may not know. Do not ask me why this happened, for I may not know. Do not ask me what to do, for I may not know. But ask me if I will try to understand, if I will think of you first, if I will stay with you, and I may be able, at last, to lift my eyes to meet yours, and say, “Yes, yes, yes, I will.”

Two of the first participants in the course, Ann Kellams, now a pediatrician, and Bryce Kellams, a family doctor, met in medical school and eventually married. They have since taken the program to other medical students at the University of Virginia, where they are on the faculty. “Bryce and I feel it’s the most important course we took in medical school,” said Ann Kellams.

In three years the course at UVA has grown from 35 students and 5 faculty to 84 students and 15 faculty. The course offers time for medical students to seriously consider issues of self-care, grief, loss, and community. “It speaks to the calling that brings people to medicine,” said Ann Kellams, “not just the science. We get reinvigorated and patients respond to that. They love it. They say, ‘Oh, finally! Someone to cheer me on or hear me out.’ It’s been amazing. It’s so simple, but it’s been so neglected and forgotten.”

For physicians already in practice, Remen is also the founder and director of the Institute for the Study of Health and Illness (ISHI) in Bolinas, California. She offers a program there called “Finding Meaning in Medicine,” which aims to address what she calls “the hidden crisis” in health care—the strains that can come from trying to practice good medicine in today’s challenging environment. Remen uses a group process to encourage physicians to listen to and support each other, and rediscover joy in their work.

The first topic the group considers is compassion. One of her initial exercises is to ask the participating physicians when they first remember being aware of the suffering of living things. Some may remember becoming aware as adults, but fully a third say they were younger than 10. “In that moment, there’s a shock of recognition,” said Remen, “that underneath the scientific dimension of medicine, there’s a deeper intention that goes back long before they ever went to medical school.” Around the country, graduates of Remen’s class continue to meet in small “Finding Meaning in Medicine” groups.

At the Center for Mind-Body Medicine at Georgetown University, director James S. Gordon, M.D., also works with practicing physicians. His program has an enduring theme: “Physicians, heal each other.”

“The heart of the work we do is about self-care as the foundation for being with others and caring for others,” he said. Gordon strongly believes that physicians must open up and shed the armor of detachment if they are to serve their patients and feel personally fulfilled.

In the Georgetown program, medical students work together in intimate small groups, where they learn meditation techniques and techniques for self-expression, with the goals of expressing and understanding the personal struggles they’ll face in school and over their careers. Crucial to the program is bearing witness to each other as they move through challenges and pain. The result, said Gordon, is an increase in the compassion that medical students feel for each other. “Our groups,” said Gordon, “hold out a hope of community to people who may feel isolated and unfulfilled in their hospitals and clinics and private offices.” Gordon’s model has been used in 18 medical schools across the country.

Family physician Wendy Buffett of San Francisco attended Gordon’s classes and says the small group work was a rich and beneficial experience. She said it has even helped her form a closer connection to her patients and get through to them. “In medicine you are always looking for that little shift, ways that you can encourage someone to take better care of themselves,” said Buffett, who is also an assistant clinical professor at the University of California, San Francisco, Medical School.

The Humanities in Medicine program at Cornell University’s Weill Medical College also helps medical students strengthen their connections to their patients. The program draws upon literature and drama to attune students to their patients’ needs, as well as to their own humanity. Dean Debra Gillers saw the need for such a program when she realized that medical students in their twenties just don’t have the depth of experience to know what serious illness, loss of independence, or the prospect of death can mean to a patient. To help them understand, Gillers has had the late writer Susan Sontag come talk about cancer and Angels in America author Tony Kushner talk about AIDS. The late novelist William Styron spoke to the classes about the debilitating depression he had experienced and written about. Equally important, said Gillers, was that Styron’s wife also came and discussed the effects of depression on their family. Last year, the program offered a reading of Arthur Kopit’s play Wings, in which the central character has a stroke and loses the ability to use or understand language. Gillers has invited patients, too, to come and talk candidly about their experiences in the medical system—both bad and good. “People want to tell doctors what worked and what they are grateful for,” she said.

The practical side of caring

At the University of California, San Francisco, School of Medicine, Charles Garfield has been talking about compassion and empathy for decades. But he has found that for many of his medical resident students, learning the technical side of medicine just proves too overwhelming. “How do values like compassion fit in when so much of what they learn in practice is the repertoire of the mechanic?” asked Garfield. “You have a disconnect when you talk of human values.”

What does make students’ ears perk up, Garfield said, isn’t the notion of better relationships with patients alone, but the idea of better compliance. Patients who feel good about their encounters with a doctor are more likely to follow medical advice, Garfield tells his classes.

Indeed, according to the giant Kaiser Permanente health organization, some 40 percent of patients, suffering from a variety of ailments, fail to follow doctors’ orders—and, says Kaiser, the major determinant as to whether a patient will follow advice, or take prescribed medications, is the clinician-patient relationship. Since the 1960s, many studies have shown that building rapport with patients—through a compassionate attitude and empathic communication, for instance—can make a substantial difference in how well patients follow physicians’ instructions. What’s more, a doctor’s communication style can affect not just patients’ adherence to medical regimens, but can influence the patients’ level of satisfaction with their care, their grasp of the facts about their condition, and can even influence the outcome of their illness. A study recently published in the Journal of Clinical Oncology, for instance, showed that just 40 seconds of compassionate communication from a physician could reduce anxiety among breast cancer patients.

While Garfield makes the point that a move to patient-centered medicine meets the doctor’s needs as well as the patient’s, he cautions that getting compassion into health care is not about tacking a few new skills onto an unchanged physician. “It’s fundamentally a different model,” he said. “We must move from detached concern to engaged concern.”

Doctors can start with caring communication. You can’t teach compassion any more than you can teach happiness, Garfield believes. But there are empathic skills that can be taught. This includes allowing patients to tell their stories— what’s sometimes called “narrative medicine.”

“In narrative medicine, simply listening is an important act,” said Garfield. “It requires that doctors do what the best healers have done through the millennium: to have the courage and generosity to listen when there are no clear answers, and to bear witness to losses.”

A matter of time

That so many programs have sprouted up, and so many doctors have embraced them, is good news for patients and doctors alike. But challenges remain. Perhaps the most oft-cited obstacle to compassion is the time factor: Just how much emotional involvement can a physician bring to an exam room when the clock is ticking?

Rachel Remen makes the point that compassion doesn’t necessarily require a slower pace, just more attention. “Compassion isn’t a function of time,” she said. “It’s almost instantaneous.” To illustrate her point, she talks about a well-known and highly respected surgeon, Dr. Norman Shumway, who died this past year. “He was also a man of great compassion,” said Remen.

When Remen’s father developed a heart problem, he went to Shumway for surgery. “My father spent a couple days in the hospital before the surgery, and he was anxious and frightened,” she said. “I was concerned about his outcome, because of his uncertainty and his fear that things were going to go wrong. I am sure that the fact he was anxious and frightened was noted in his chart.

“The day before the surgery, I came to see him. I asked him how he was feeling and he said, ‘I feel really confident.’ I asked him what had happened. He told me he had been standing in the doorway of his room, wearing one of those hospital gowns and paper slippers, when Shumway came walking down the hall, followed by a group of people. He saw my father standing in the doorway, and he stopped. He took my father’s hands in his, a double handed hand shake, and he said, ‘Mr. Remen, I’m Dr. Shumway. Are you feeling strong?’ My father, feeling his hands being held that way, nodded, and Shumway said, ‘I am too,’ and gave my father’s hands a squeeze. He said, ‘I’ll see you tomorrow in the operating room.’

“My father was transformed,” said Remen, “and the whole encounter took no more than 50 seconds.”