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I recently met an anaesthetist called Robin Youngson who has had a most unusual career. He was brought up in various parts of the British Empire, as what he describes as an ‘army brat’. He went to an English boarding school where he was badly bullied, before going to university and becoming an engineer. He then worked in oil exploration, saving up money in order to study medicine. He emigrated to New Zealand, where he became a senior anaesthetist. However, over the course of time he came to feel that there was something profoundly wrong with the way that he and most doctors were practising medicine. He gradually became aware of the automatic and detached manner in which he and his colleagues were working. ‘As a doctor’ he says ‘I was the one to set the agenda, I had a single track purpose that I relentlessly followed regardless of what was important for the patient.’1 He realised that he had experienced a kind of brutalisation in his medical training, similar to the experiences he had suffered at school. He acquired a belief that the only way to transform this approach to health care was for everyone to practice systematic kindness, both to themselves and those around them.
He started to change his own behaviour, especially towards patients he had previously seen as ‘difficult’, or towards colleagues who had seemed ‘unco-operative’. He observed the positive effects this had on them. He applied the same approach to teams and institutions, promoting compassion as an aspect of quality improvement projects, patient safety initiatives and organisational change. He began to collect evidence both in New Zealand and from around the world, to show how improvements in attitudes and behaviour can improve medical care. In 2012 he founded ‘Hearts in Healthcare’, a movement dedicated to rehumanizing healthcare.2 He now lectures internationally on the subject, with a simple but compelling message: compassion is not just a cosy add-on to good technical care. It is the most important factor in achieving good health outcomes.
In a book entitled ‘Time to Care’,3 Dr Youngson brings together different strands of his experiences and ideas, and the evidence in favour of compassionate care. He writes of how health care has become industrialised, with an emphasis on carrying out mechanical tasks rather than making an emotional connection with patients, often leading to burnout and disillusionment in health care staff.
ACTS OF KINDNESS
In his book, Dr Youngson describes the personal impact on him when individual patients helped him to behave spontaneously instead of ‘correctly’. He also writes about a time when his daughter was involved in a life-threatening car accident, and he found that small acts of kindness by hospital staff gave ‘indescribable comfort’ to himself and his wife. Dr Youngson criticises the way that doctors and nurses are forced to conceal their vulnerability, building up an emotional ‘armour’ that causes harm both to themselves and their patients. He draws extensively on fields like positive psychology, mindfulness, meditation studies and neuroscience, to build a case in favour of caring for yourself and loving your work – as a pre-requisite to being an effective health care professional. He points to the paradox that, when you are under pressure, it is better for you and your patients if you slow down or even to stop than to drive yourself even harder.
This is all persuasive as a moral argument, but people will want inevitably to know about specific interventions, and evidence of improved outcomes, before investing time and money in something as nebulous as kindness. ‘Time to Care’ includes a number of examples. In a hospital in Alabama, for instance, a chief nursing officer told staff they should see every patient once an hour to inquire about the need for pain relief, a visit to the toilet, whether they needed turning, or if they could reach everything they needed. The nurses found their work was interrupted less frequently, and they walked a mile less per shift, while patient falls declined by 58% and bedsores by 39%. Patient satisfaction scores rose, and so did results on a questionnaire asking if they would recommend the hospital to their family and friends.4
In a similar project in the United Kingdom, leaders increased the time that nurses spent on direct care by 20%, and consequently cut handover time by a third, reduced the medicine time round by 63% and cut meal wastage rates sevenfold5 One nurse commented: ‘The ward usually appeared calm – however busy. There was a place for all equipment so it was less cluttered, cupboards were tidy and only contained what was actually needed; vital observations were recorded, there were less patient falls, reduced drug errors, and above all, happier patients and staff.’
IMPROVED JOB SATISFACTION
In another American project, four hospitals in Virginia put wide range of caring measures in place, including a dedicated nurse for admissions and discharges on each ward, a telephone voicemail system for handover, thus freeing up far more time for direct nursing contact.6 Here too, nurses reported improved job satisfaction, while the average admission time for each patient reduced by 20 minutes.
Compassionate care can affect health outcomes and lower costs as well. In a randomised controlled trial published in the New England Journal of Medicine, patients who were given earlier palliative care for metastatic lung cancer survived longer, in spite of having less aggressive cancer treatment.7 They also had a better quality of life, and a lower incidence of depression. In another study across 8 hospitals, access to palliative care reduced the costs of cancer care by an average of $1696 in those who were discharged home, and $4908 in those who died in hospital.8 As Dr. Youngson comments, the question is not ‘How can we afford compassionate care’ but ‘How can we afford NOT to re-humanize our healthcare system?’
Health is indivisible. Paying attention to the welfare of patients cannot be separated from thinking about our own welfare, and that of our colleagues, teams and organisations. There is an emerging science of subjectivity, which has just as much to teach us as the science of objects that now dominates our training and practice. It tells us that good technical care is inseparable from good emotional care. We need as much research and investment into caring human relationships as we do into drugs and machines.