Solving the crisis of compassion in New Zealand medicine will require changes to the system, although mindfulness can also help, says one of the organisers of the country's first compassion in healthcare conference.
Tony Fernando* is a psychiatrist, sleep specialist, senior lecturer in psychological medicine at the University of Auckland, and compassion specialist who was temporarily ordained as a Buddhist monk.
He is one of the organisers of New Zealand's first Compassion in Healthcare Conference, starting 16 March 2019.
He says compassion is a natural instinct.
"All of us - or most of us - have a natural tendency to be kind because we're a pro-social species," he says.
"We depend on each other."
However, he says slipping into callousness can also be part of the human condition.
"It's something I have seen and witnessed and it's a situation where I can see myself in the same situation given the right - or wrong - circumstances.
"We get used to things which - even though we know what's going on is wrong … if the whole culture accepts something that's wrong as 'right', or as 'okay', or as 'the norm', it becomes the norm and we become blind or we become callous."
He says that was the case at Stafford hospital in England in the late 2000s, where one inquiry showed "hundreds of patients died in appalling care and a disturbing lack of compassion".
Crisis of compassion
The Stafford result didn't surprise him, he says, and New Zealand is undergoing its own crisis of compassion.
"I might be exaggerating a bit, but looking at the data that we have in terms of health providers, the incidence of … compassion fatigue and burnout is scary.
"I think in New Zealand, even the local union, ASMS, our Association of Salaried Medical Specialists … found about half of consultants, senior doctors in New Zealand are experiencing burnout.
"If about half of our health providers are burnt out you can imagine the consequences in terms of how they deliver care … and we're not even talking about nurses yet, we're not even talking about social workers.
"If half of your staff are burnt out, that for me is a crisis."
He says mindfulness can help doctors be more compassionate, but there's more that needs to be done to address the stresses health professionals are under.
"It's not just training the doctor to be more compassionate, to be kinder, that's just one aspect.
"Even if I'm a generally kind doctor, the environment - like constant interruptions; or I feel like my boss doesn't actually support me; or I feel threatened in the system - my natural tendency to care will drop.
"Patients can drive us nuts, the system can drive us nuts, it's not just us. Of course we have a role to play - our personality, our lack of kindness to ourselves, [if] we don't sleep.
"First of all, I think we need to address the system."
Fixing the system
Dr Fernando says the problem is people have less compassion when they start to run out of resources.
"The brain will get fatigued if it's tired, if it hasn't slept, so as a junior doctor you're required to see the next 30 people who require contact and assessment and knowing that you still have to work the following day and you will not sleep … you run out of resources."
He says that's what happened at Stafford, where staff were under huge amounts of pressure with the hospital trying to save money.
He says he can imagine himself falling into the same trap.
"I'm not doctor compassionate forever.
"In a busy clinic which starts at eight, and I only have a 10-minute lunch break - which I'm avoiding now because I know my compassion levels drop quicker … I know that by three o'clock my compassion levels are tanking."
Fixing the system, then, is about making sure health professionals have time to recover and have the energy to keep doing their job.
Mindfulness and the compassion muscle
Still, if the system is good, Dr Fernando says teaching mindfulness on top of that can help.
"We need to up-skill people and this is where different mind training can be helpful."
He says while the idea of compassion fatigue is useful for people to be able to self-diagnose their stress, it's not a term he's a fan of.
It suggests that compassion must be rationed, but Dr Fernando says rather it's your energy that needs rationing.
"Being compassionate regularly does not make someone fatigued," he says.
"The reason I am trying to tease this out - that compassion is not necessarily tiring - is there is this concept … of compassion satisfaction.
"Feeling good, feeling meaningful when we're kind. When people are actually kind and they know that they're doing something meaningful it actually feeds the whole kindness, compassion machine."
He says training can also improve your capacity for compassion.
"This is where the Buddhist hat can come in - interestingly with training and being in the right mindset your compassion resources can jack up.
"You become resilient. You start to notice suffering but at the same time you have this - in a way - a compassion muscle.
"If you're a little more mindful, you're more aware that 'hey, hang on, instead of wanting to care for this patient I have this urge to slap the person'."
He says he's noticed the effect in his own practice.
"[I say to myself] 'this is a difficult situation, Tony, have a couple of breaths, it's all right'.
"And then I remember that these people are probably in a lot of pain, that's why they're difficult … I view them as suffering and then the natural tendency to care and be open ensues."
Still, Dr Fernando warns mindfulness "just doesn't work for some people" and is not a panacea.
Perfection and 'being kind to yourself'
He says while the common understanding of mindfulness is awareness of the present moment - thoughts and feelings - there is more to it than that.
"Continuous awareness of the present moment, [being] accepting, non-judgmental; and with lots of kindness to self."
Like other high-stress professions such as lawyers and architects, people in medicine often tend to struggle with that last point, he says.
"I work at the medical school so I deal with a lot of extremely bright, high-functioning, high-performing students. A fair number of them are actually very hard on themselves.
"If they don't get the top marks, that's a fail. If their supervisor makes a not-so-nice comment about them their whole world collapses."
He says a little bit of perfectionism can be useful and motivate people to be better, but too much can have negative results.
He says they're less likely to respond to treatment and training in compassion, too.
Luckily, people can learn to be kind to themselves - and part of the point of the conference is getting doctors, nurses and related professions to recognise that they're not necessarily to blame.
"They looked shocked, like 'oh, I never thought about that' because a lot of doctors when they're burning out, they don't look for other reasons most of the time.
"The problem is in medicine - not just in medical school but in many layers of medical training - there's this idea that we have to fix everything.
"My experience has been people tend to blame themselves. And .. what we're talking about - looking at this from a transactional or systems level - is different to the message of so many people.
"'There's something wrong with you doctors, you need to be more resilient; nurses you need to meditate'. It's annoying to hear that all the time.
"We have a role to play, but it's not just us that's causing this."
* Tony Fernando was awarded in 2012 by President Aquino of the Philippines for his services to sleep medicine and medical education. In 2015, he received the Chair's award from the New Zealand Medical Association - the highest recognition given by the association to any doctor in New Zealand - for his work on physician wellbeing.
He received temporary ordination as a Buddhist monk in Myanmar in January 2017 and recently started a weekly mindfulness and emotional balance programme for inmates at Mt Eden Corrections Facility in Auckland.
He is now in the final stages of his PhD at the University of Auckland, studying compassion in medicine.