Humanism, compassion and the call to caring

Health professions education is at an important juncture. A series of pivotal reports call for significant reform in the way students are prepared for practice in an increasingly complex health care environment.1-3 At the same time substantial work is emerging to illustrate that health professionals are struggling in record numbers with burnout, depression, suicide and challenges of identity formation,4-7 which may arise from exposure to disparities between formal curricular teachings and messages imparted through the 'hidden curriculum'.8 The Flexnerian revolution of medical education in the early 20th century achieved the much needed result of propelling the scientific dimensions of education, but even Flexner himself noted as early as 1925 that the humanistic dimensions remained under-emphasised.9 The successive decades have been characterised by dramatic scientific and technological advances accompanied by astounding increases in cost (and consequently the rise of medicine as a 'business'), forces that may challenge a commitment to humanism. In the mid-20th century, George Engel advanced the concept that quality patient care requires attention to the biological, psychological and social dimensions of a person's illness.10 The 'patient-centred'11, 12 and 'relationship centred'13 care movements soon followed, and most medical schools now incorporate formal reflective practice, communication skills and professionalism curricula, beginning in the first year. Yet when our students reach the wards and clinics they may find that their role models exhibit very different behaviours with real patients to those they practised with standardised patients.14-16 Further, although communication in clear and caring ways with team-mates and multidisciplinary colleagues is increasingly considered to be an essential skill, standards for teaching, assessment and practice have not yet been established.17 However, humanism is more than learning how to display empathy and appreciate another's perspective. It can be argued that humanism also involves learning to recognise and navigate tensions between values (empathy and objectivity, efficiency and quality, standardised and individualised care, for example) and to understand the ways in which power and privilege affect health care and learning interactions. There is a tendency to reduce relational issues in health care to an individual competence requiring individual approaches (supported by a proliferation of assessment tools), while neglecting the influence of systems and culture on relationships. Approaches to cultivating humanism can be thought of within four domains: intrapersonal (e.g. mindfulness, reflective practice), interpersonal (e.g. communication, empathy and teamwork training), systemic (e.g. improving systems and cultures to allow humanism to thrive) and population based (e.g. addressing biases, assumptions and ingrained practices that affect health outcomes, and advocacy efforts). (Haidet P. Discussion of four domains of humanism in healthcare. Pers. comm. May 2015. Gold Foundation Symposium in Chicago, USA.). There are many gaps between what we say we value in the health professions and what we actually do: the gap between the techno-scientific and the caring dimensions has become a yawning chasm, and medicine as a humanistic pursuit often is at odds with medicine as a business. As educators move strongly in the direction of defining competencies18, 19 on which to base education, there is a risk of reductionism and an urgent need to safeguard notions of humanism, caring, compassion and justice20 in these frameworks. This is important not only because our patients will feel more comfortable and our clinicians will find more joy and meaning in their work, but also because compassionate health care is better health care.21 Leaders in health professions education and practice settings in North America and around the world22 are responding with efforts to harmonise the technical and corporate aspects of health care interactions with the compassionate and humanistic. Two of these leaders, the Arnold P. Gold Foundation and the AMS Phoenix Project, have partnered with Medical Education to open a space for conversation and exploration about humanism and compassion in health care. Established as a USA not-for-profit organisation in 1988, the Arnold P. Gold Foundation works to infuse a culture of respect, dignity and compassion in health care settings. The Gold Foundation's signature programmes include rituals such as the White Coat Ceremony, awards to honour exemplary humanistic role models, and initiatives in the domains of education and service. The Arnold P. Gold Foundation Research Institute, established in 2012, has set out to 'map the landscape' of humanism in health care by supporting works that review and synthesise the literature in this domain. AMS is an Ontario-based charitable organisation that has funded many successful projects in health care and education, including the AMS Educating Future Physicians for Ontario project in the 1990s, which created the competence role framework that would later be adapted by the Royal College of Physicians and Surgeons of Canada as the CanMEDS roles.23 In 2011 AMS launched the AMS Phoenix Project: A Call to Caring. The vision of the project is to nurture and sustain the learning and practice of compassionate care. The Gold Foundation and the AMS Phoenix Project have aligned their energies to stimulate academic writing consistent with their goals. The two organisations' blogs (http://humanizingmedicine.org/; http://theamsphoenix.ca/blog/), commissioned papers and conferences, as well as this collaborative theme issue, provide venues for scholarly work related to humanism, caring and compassion. We are pleased to present this themed issue, recognising that there are many dimensions to the field that will be explored in future publications. These papers and commentaries are just the beginning. As we map the landscape, we realise that we have much work to do to nurture compassion and humanism in health care. First, we need to develop a shared language for rigorous inquiry into this domain, as traditional methodologies developed for biomedical research often fall short. And of course we need to remember that good research is simply a means to an end. Ultimately, we hope to translate research into the practice of embedding humanism as a core value in our health professional schools, in clinics and hospitals, and in board rooms and legislatures. Coupled with advocacy efforts, our research will find its way into accreditation standards, will influence clinical practice and policy decisions, and propel much needed change.

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