Values in Healthcare: caring for doctors
As practicing surgical oncologist for more than 35 years, most of them in a major cancer hospital, I realize how important it is for doctors to sustain our own wellbeing and prevent “burn out”. Despite improvement in disease management, there is a decline in sense of purpose and general unhappiness amongst health professionals. This can have a harmful impact on the care of patients. Recent experience as medical director of Global hospital, however, I have found that measures to rekindle the experience of the higher values we share as human beings can bring rapid improvement in both individuals and institutions. Reminding ourselves of these values and focusing on them in the training and ongoing support, is a way to restore morale and enthusiasm. There is a saying that “Charity begins at home” and home is not just other people that we are close to; it begins with the self.
British Medical Journal posed the question in an editorial: “Why are there so many practitioners who feel burdened? Why do so many physicians wallow in woe?” A writer, from USA, felt that our spirit, our morale, had drained away; that we had forgotten that taking care of people is the greatest honour we could have.
Doctors in particular need to know how to care for themselves, because if they do not, they will not be able to give optimum care to their patients. Our ability to care depends to a large extent on our own experience of being cared for and valued, similar to the experience of having been brought up by good parents. If institutions have a responsibility to provide care for patients, then they also have a responsibility to sustain the doctors who deliver that care. Slogans like “putting patients first” have become fashionable but this principle has been forgotten.
When institution encourages a culture of care, it contributes significantly to the quality of treatment patients receive. Tiredness and emotional exhaustion can affect judgment
but perhaps, a doctor’s faith in himself and respect for himself is conveyed automatically to the patient, affecting the patient’s faith in his or her treatment.
If a doctor feels insecure and unhappy, he does not listen properly either to patients or colleagues. He is less likely to perceive the complexities of a patient’s condition, and he will find it difficult to collaborate in teamwork. He will be unable to offer the kind word, gentle touch or loving look that can mean so much to patients – and to colleagues too, when they are under stress. A supportive work environment helps to contain or minimize the impact of a staff member’s weaknesses, such as trying to control others just for the sake of it, or acting out of a need to be liked rather than doing the right thing.
Even though these qualities sometimes seem to have been lost beneath the weight of considerations such as shortage of time, or the need or desire to earn money or status, such higher qualities never disappear. They are innate to our humanity, and can be recovered quite readily. When that happens, work becomes enjoyable again.
Renewing values is part of the process of renewing energy and goals. But we do not strengthen our values just by talking about them, or writing them down in a mission statement. That can make us feel even worse, by highlighting the gap between what we are actually doing, and what we say we would like to do. We have to learn to understand our higher values deeply, to see where they come from, and put them into action.
Values can be described as principles or standards of what is valuable or important in life. Knowing and living our values can help us understand the purpose of our lives. They are fundamental personal truths, which when we understand how important they are to our happiness, we will not betray. They include our commitment to behave in a just and right manner, with all who come into our contact. They enable us to find the right balance between work, rest and play; they help us to distinguish right from wrong.
Values are not like static rules. They can be used in a dynamic way, in our daily practice. For example, a London psychiatrist who helped to develop the values programme tells of when a physician sought her advice on whether to carry out major procedures on a patient with very poor quality of life. The psychiatrist asked, “What would be kindest for the patient?” You could never find an answer to a question like that in a textbook, but by raising the important value of kindness, this helped the physician solve his problem.
To recover awareness of such values, an approach using facilitated small-group experiential learning has proved very effective. Time is allowed for silence, reflection, meditation, and sharing in small groups. We used the “Values in Healthcare”, a programme developed by JF, which focused on three key principles: (1) “Physician, heal thyself” (2) Learning through experience (3) Relevance to work
v Physician heal thyself – codes of medical ethics across the world include requirements for competent medical advice, confidentiality, no harm or injustice to the patient, and working with compassion, love, sympathy and respect to human dignity. These are seen as our profession’s greatest assets, greater even than scientific knowledge and technology. However, over recent decades they appear to have been sidelined in our training. We support and develop the personal wellbeing of the doctors rather than focus only on improving their clinical skills. The programme raises morale and gives a sense of purpose.
v Learning through experience – traditionally, formal lectures, personal study, tutorials and practical experience are used alongside apprenticeship learning. Little guidance is given for enhancing the qualities of calmness and compassion expected of doctors. Paradoxically, and unintentionally, these qualities may actually be trained out of us. It was therefore decided that these qualities could best be explored through direct inner experience. An approach using facilitated small-group experiential learning was adopted. Time was allowed for silence, reflection, meditation, and sharing in groups of two and four in a supportive environment to encourage the discovery of personal values
and insights.
v Relevance to work – Rapid changes in society, organizational structures, medical and informational technology and patients’ expectations have led to additional burdens on healthcare professionals often resulting in states of chronic tiredness and demoralization, and emotional and physical exhaustion (burnout). We have found that stress and its consequences can be addressed by working with certain key values “peace”, “positivity”, “compassion”, “cooperation”, “valuing yourself” and “wellbeing – taking care in practice”.
At Global hospital in Mumbai, this type of approach has contributed significantly to a culture of care that is providing a healing environment for staff and patients. Programmes were conducted for both the medical and administrative staff members giving them space to interact and to experience and express their individual creativity, uniqueness and specialities. In the interactions, we use a technique called appreciative inquiry, which focuses on ascertaining the best in each other, eliminating the common practice of criticism. With such methods, trust both in the self and others grow, a sense of personal empowerment increases, and the ability to care appropriately for the self, colleagues and patients is restored.
We have used a model of mind-intelligence-personality, which controls thoughts, emotions, attitudes, feelings and judgments. Anything we speak or do first starts in the mind as thought. These are positive, negative and waste thoughts. The intellect judges/balances the pros and cons driven by thought and it guides words and determined actions. The key we have used in practicing value based medicine is empowering the mind daily by morning meditation a 30-minute sitting in silence and giving positive direction to the thoughts using powers of love, happiness and peace – looking at the brighter side of every difficult situation, and maintaining a positive attitude. Many complaints, conflicts and situations challenging our values come up in real life. The empowered mind is able to handle these difficult situations with relative calmness, confidence and compassion looking at the situation holistically.
Dadi Janki, 90 years, President of the Janki Foundation, a former nurse who still sustains herself and others so well that she is in constant demand as a speaker around the world.
“When the mind learns how to sustain peace, and the heart knows love and happiness, healing takes place. This healing can be shared………because feelings of peace and happiness also reach others.”