The Subtle Power of Compassion

JAMA Vol. 286 No. 24, December 26, 2001

Teresa Gilewski, MD

He stood before us and said he wasn't sure that he had anything to say that would be worthwhile for us to hear. I suppose that some in the audience initially wondered the same thing. As his story unfolded, however, he easily pulled us into his world, 15 years ago, when he began his struggle against cancer. He was a tall man with an athletic physique, so it was difficult to imagine him 60 pounds lighter, bald, and enduring the physical and emotional pain that came with his illness. His plans after graduation from college were drastically changed with the discovery that he had metastatic testicular cancer. For three years he underwent numerous chemotherapy regimens and operations to treat the cancer and its associated life-threatening complications. Much of that time he was hospitalized. He was told repeatedly that his chances for survival were minimal and, with his third recurrence, that his death was likely imminent. After his treatment was completed, he began to live, tentatively, in three- to six-month blocks, uncertain of his future. Yet he now stood in front of us, after having accomplished an amazing list of feats, humbly telling us about his life as a patient, something he rarely talked about.

This patient, whom I will call Michael, was eloquent and spoke with a sense of humor, recalling his stories so clearly and with such deep emotion that, at times, it was almost too painful to listen. Sometimes the inadequacy of words was replaced with his silence and tears. In those moments, even though we were strangers, he gave us the opportunity to feel the periphery of his suffering and to try to understand the depth of his experiences. He spoke about those moments that made a difference to him during that time. I was moved by his honesty, and although ironically he never used the word compassion in his talk, it's the essence of what he spoke about. After his talk, I felt compelled to write about compassion, not because I have anything profound to say or a markedly new perspective. It's simply that I think it's easy to forget about the power of compassion when we are focused so often on the power of science.

Michael's stories reminded me that compassion is as important as competency and trust, in a truly meaningful interaction between patient and physician. Years later, this patient remained obviously touched by moments of compassion that enveloped him with a comfort from knowing that others wanted to alleviate some of his sufferingeven if at that particular moment they could not completely understand it. Compassion has been defined as "benevolence, commiseration, empathy, humanness, and kindness." However, I think that author Joseph Campbell's description of compassion as "suffering with" is most meaningful.¹ It is "suffering with" patients for a few seconds or minutes that can create a special bond. Michael recalled an intern who often took a "few extra minutes" at the end of the day to talk with him about different topics, usually not related to his illness. At other times, this intern would return after rounds to explain some medical terminology. After finishing his last cycle of chemotherapy, Michael did not have much communication with this intern anymore. Yet, many years later, with tears in his eyes, he remains overwhelmed with gratitude for the compassion shown to him by this young physician. In retrospect, though, he felt that he never adequately expressed his thanks to that intern.

It is difficult to dissect what happens in those "few extra minutes" that can make such a difference for a patient. Michael poignantly remembered, "After a while, you think of yourself as a chart rather than a person. Those 'extra moments' made me forget I was a patient. I felt like a person again." What happens in those minutes for the physician? I can't speak for the intern, but I do recall some of my own experiences. During my medical training, I sat one night next to my patient, five years younger than I, whose body was ravaged by melanoma. Yet her spirit was indomitable. It was the Christmas season and she told me that was her favorite time of year. She said, "A year ago I was so happy and now it's Christmas againand I'm dying." I could barely keep the tears from rolling down my face. I felt such sadness and such disillusionmentall I could really do to help her at that moment was to hold her hand. In some of those "extra moments" spent with patients I've heard about unfulfilled dreams, fears, and relationships. Sometimes I forget how much I've learned about life from these people. Perhaps the essence of those "extra minutes" is that by "suffering with" the patient, the patient-physician relationship is temporarily suspended and transcends to one of human being to human being.

Michael described our medical training as a sort of boot camp where one can become desensitized to feeling. He understood how this could happen, yet he was so grateful when someone remained "sensitive" to his suffering. Michael provided an unmistakable affirmation that compassion does not require lengthy periods of time and that it can have a profoundly positive, lasting impression, an impression the physician may never realize. At one point he remarked that "patients aren't looking for a best friend in their physician, but any little extra kindness means so much."

Michael's stories reminded me that the facial expressions, mannerisms, and words of physicians can convey compassion as well as have hidden meaning for the patient. Nuances that would normally be considered inconsequential become unusually significant. Michael recalled an instance when in the middle of the night two interns told him of his need for emergency surgery and that his chances for survival were minimal. As he recounted this experience years later, he specifically noted that these interns had tears in their eyes. On some level, their compassion and their sadness about his situation made an impact on him. He also recalled his familiarity with the gait of the attending physician as he walked down the hall, so that when it changed from a fairly fast clip to a slower one, Michael felt this "foreshadowed" bad news, and he was right. When the physician spoke to his family outside his room in whispers, this also fueled feelings of anxiety and fear. At one point he expanded on the words used to describe the size of a tumor in his lung. One physician characterized it as the size of a quarter and another as the size of a half dollar. This prompted Michael to spend an inordinate amount of time measuring the size of these coins in an attempt to determine the meaning behind these different descriptions.

Michael's emphasis on the meaning of words and mannerisms was jarring, since these are often not a particular focus of physicians. During a busy day, these specific elements of communication have not always received my attention, and yet they can leave a lasting impression on a patient. I felt a certain sense of comfort knowing that Michael did not interpret the tears shed by the interns as a sign of weakness. On the contrary, he viewed it as a sign of their compassion and humanness and felt that it did not detract from their ability as physicians. I have cried for patients in private, yet on occasion, when the sadness is overwhelming, I've shed tears with a patient or with family members. Although it always seemed right at the moment, in retrospect I've wondered how it was perceived.

Michael's stories reminded me that despite their own anguish, patients can also offer compassion to others. Author Jean-Dominique Bauby poignantly described patients as "those castaways on the shores of loneliness."² Physicians are often aware of the despair that accompanies illness, yet do not always understand what this really means for the patient. During the millions of moments of loneliness when Michael was tired of fighting, lying in his bed, short of breath, on oxygen, aware that his chance of survival was minimal, he told of searching for reasons to continue his difficult struggle for life. He thought very hard about finding the ultimate purpose for his lifesomething that he could dream about and hold on to. However, while he was focusing on these issues, other patients would sometimes turn to him for comfort. Michael recalled one patient who became his friend. They would discuss their lives, their illnesses, their hopes for the future. This patient often visited him, hoping for a chance to talk. Sometimes Michael would respond and other times he didn't feel like talking. The other patient would leave, trying to hide his disappointment. One day Michael returned for treatment and learned that his friend had died suddenly and unexpectedly. Michael's regret over missing several opportunities to be compassionate toward this other patient was apparent in his voice. It made me think of the many similar opportunities that I had also missed.

Michael's insights reminded me that we are all a heartbeat away from our own "unexpected" death. Michael said that eventually he accepted death and learned to "embrace" it as part of life, but it wasn't easy. He recalled an episode as a boxer, when in the heat of the moment after a fight, he hugged his opponent and told him, "Wow. Wasn't that something." Now he uses the intensity of that experience to describe his views about death. He said that he will be sad when death comes for the final round, but will greet it like an old friend, look back on his life, and say, "Wow. Wasn't that something." Although Michael didn't discuss it, I wonder whether his or anyone's true acceptance of mortality and subsequent passion for life involves an element of compassion for oneself. Perhaps we need to empathize with our own fears or, in other words, "suffer with" ourselves every once in a while, to really appreciate this temporary stateof lifethat we find ourselves in.

Michael's stories and thoughts reminded me that compassion is an integral part of medicine. The power of compassion is subtle. It may never be acknowledged by the recipient. It may never be rewarded by a promotion or public recognition. Sometimes it comes across in a few words or a smile or a kind glance or a few extra minutes of time. Yet its effect can last a lifetime. Compassion is intertwined with the science of medicine in that the ultimate purpose of both is alleviation of suffering. Yet it's accomplished in different ways. Science is measured but compassion is felt. The opportunity for compassion presents itself every day in every outpatient clinic, in every patient room, and in every hospital hallway. Many of these opportunities may be lost because the value of compassion is not always recognized.

Yet Michael reminded me that compassion is of valuethat it is a powerful element of the patient-physician interaction. Without it something is missing. Perhaps it is because compassion brings us to the core of our humanity. Michael inspired me to reexamine my responsibilities as a physician and as a human being. He taught me because I listened.

I need to listen more often.

AUTHOR INFORMATION


Teresa Gilewski, MD
New York, NY

Acknowledgment: I gratefully acknowledge several colleagues, especially Joseph Simone, MD, for their helpful critiques of this essay. I am most grateful to the patient in this article, for allowing me to tell part of his story. His extraordinary honesty and courage provided us with a unique opportunity to better understand the value of compassion in medicine. On behalf of those who were privileged to listen to him, I offer our deep admiration and appreciation.

REFERENCES

1. Campbell J, Moyers B. The Power of Myth. New York, NY: Bantam Doubleday Dell Publishing Group; 1988:201.

2. Bauby J. The Diving Bell and the Butterfly. New York, NY: Vintage Books, Random House Inc; 1997:29.

Edward E. Rylander, M.D.

Diplomat American Board of Family Practice.

Diplomat American Board of Palliative Medicine.