Michael Vassallo
Bournemouth, United Kingdom

Is medicine an art or a science? As a medical student embarking on a journey, the answer seemed obvious. I was one of a unanimous chorus of students confidently claiming science as the answer to this trick question. My mum, however, told me “to be kind and smile, appearing serious or pompous makes the patient feel ill and does not help recovery.” As time goes by I realize the wisdom of this advice.

Regrettably we often hear appalling stories of uncompassionate care in hospitals and care homes.¹ We now feel the need to teach compassion. I do wonder, however, how do you teach something that has to be felt? If compassion is about human kindness then is that not something that should come naturally? Indeed, Gilbert suggested that compassion is a manifestation of behaviors that have evolved in primates for parenting to enable survival.² Nevertheless, it takes nurturing to develop this instinct into true compassion, which is more than empathy or feeling for somebody else’s pain. It also requires the drive and the knowledge to act to help ease that pain. Before dismissing kindness or compassion as nebulous or abstract, there is increased scientific acknowledge of neuroendocrine mechanisms explaining this art. For example, Silani, et al., found that the right supra marginal gyrus in the brain regulates empathy and compassion and when this does not function properly or when we make quick decisions, our ability to show empathy is dramatically reduced.³ Hormones such as oxytocin enable mammals to engage in close personal relationships.⁴ The personal tendency for compassion is dynamic and with this better understanding of the neuroscience, the question arises whether compassion can be thought. There is increasing evidence that it can.⁵

Teaching compassion should start from childhood through family, schools, and for many, religion. Compassion, motivated through various religions from the time of Buddha, has driven the development of hospitals and health care⁶ and it is hoped that compassionate people would come to health care as it is a fertile area needing such people. At a recent General Medical Council event on the compassionate doctor, 55% of respondents to a Twitter poll agreed that medical students’ empathy drops as clinical exposure increases.⁷ This has been confirmed in more formal studies^8,9,10 where it was suggested that the biggest decrease in empathy occurred after the third year of medical school. There is therefore an obligation to teach compassion to individuals because the teaching of medical science may adversely affect compassion. Various programs based on principals of psycho-cognitive education, including mindfulness, cultivation of emotional balance, and cognitively-based compassion training have been developed.^11,12 It is not wasted time as teaching compassion has its benefits to all working in health care. Institutions with a reputation for inhumane care are unable to compete financially, face litigation, complaints, and closure. Patients benefit through increased treatment concordance, satisfaction, and better clinical outcomes. Physicians gain through lower depression rates and lower burnout.^13,14,15

One needs to develop the environment and the culture for compassionate care before teaching compassion. In an organization that does not promote compassion, good people risk doing bad things. In an age when success is measured by metrics, cost effectiveness, cost improvement programmes, and performance management, it is easy to see patient needs getting lost in the pursuit of impersonal outcomes. As organisations now endeavor to develop patient-centered care, we seem to think that we are developing new things. We forget that before the science of compassion existed there was the art of caring and that compassion has been at the heart of it for centuries. Models from the past do show how this was done.

Walking around the Mediterranean Conference Centre in Valletta Malta, I came across this plaque referring to “Our Lords the Sick” (Fig 1). This place has lots to be proud of—impressive architecture, site of one of the earliest schools of anatomy and surgery in the Mediterranean founded in 1676, and it really hit the headlines when Sir David Bruce discovered the microbe Brucella melitensis.¹⁶ Despite there being a great deal to celebrate, “Our Lords the Sick” was the chosen statement representing the values of the place, celebrating caring rather than discovery or achievement. The building itself was first built as the Holy Infirmary (Sacra Infirmiria) of the Knights of Malta in 1574. It was built on a site of great devastation in the aftermath of the great siege of Malta in 1565. It was one of many buildings in the city built under the leadership of Grand Master Jean Parisot de Valette who wanted to strengthen the defenses of the island against further invasion by the Ottoman Turks.

The Knights were a Catholic order of monks and it is not surprising that this statement’s origins lay in Christian spirituality itself, inspired by the words of Christ “Whatsoever you do to the least of your brothers, that you do unto me.” Helping the sick and the poor was therefore considered at par with helping Christ himself. For a Catholic order, this was a powerful mission statement in setting the standard to drive a culture of care and compassion. It was certainly very powerful in the Middle Ages, when the prospect of burning for eternity in the fires of hell was very real. Some may argue this statement is not relevant in today’s secular world and certainly each organisation needs to give a message that touches the values of the people working within it. However, even today everybody has a lord or lord equivalent. That lord may well be a God from a different faith, a high ranking individual, a relative, a possession, or even oneself. The development of a culture of compassion requires that the sick, whoever they are, are treated with the same dignity and respect as someone or something very dear or very important.

Mission statements need to be followed by actions. George Sandys, the famous English Traveller, was in Malta and in his book The Relation of a Journey wrote “. . . St. Johns Hospital doth merit regard not only for the building but for the entertainment there given, for all that fall sick are admitted there unto. The knights themselves there lodge when hurt or diseased, where they have physic for the body and for the soul also. The attendants many, the beds overspread with fair canopies, every fortnight having change of linen. Served are they by the junior knights in silver, and every Friday by the Grand Master, accompanied with the great crosses. A service obliged unto from the institution and there upon called “knight-hospitallers.”¹⁷ In this account one can pick up many features organisations now aim to implement to underpin patient centered compassionate care and more.

Leadership is crucial in establishing the culture. Here is a fine example of leading from the front where the Grand Master as the supreme head of the order periodically visited the hospital putting on an apron serving food to the sick. Knights too were expected to take care of the sick. Talking to the sick to ascertain that they were well treated, that they were given medication and all needs were attended to, was one of the roles of the prodomi.¹⁶ In today’s parlance, a middle manager promoting quality through patient feedback. The organisation admitted all sick regardless of status. Knights, common people, illegitimate children, and slaves without discrimination all were treated. Sandys also hints at infection control. A linen change every fortnight is hardly impressive by today’s standards but it was worthy of mention back then. Plates were made of silver not out of vanity but because they were easy to clean.¹⁶ Tenzin Gyatso, the 14th Dalai Lama said “ . . . Caring for others requires caring for oneself.”¹¹ The knights being experienced hospital administrators deliberately or intuitively recognized this and knew that grand ideals alone are not enough to motivate the workforce, especially when what is now known as compassion fatigue sets in. Staff were plentiful. Over time a career structure was set up to ensure progression and ensure that the hardest working are properly remunerated.¹⁶ Maid-nurses were encouraged to train as barber surgeons and in fact by 1728 several female barber surgeons were practicing and in 1772, a young woman was sent at the order’s expense to study surgery in Florence.¹⁸

When I look back to the books I studied from thirty years ago it is striking how outdated they all are. It is no surprise that medical students hungry for learning new knowledge seem to have lost track of the fact that medicine is not only about offering the latest diagnostic investigation and treatment but also about compassion, kindness, respect and bedside manner. Although the science has and is changing, the principles of the culture of care and caring have not changed and it seems science has done little to deliver compassionate care. At times when the science has nothing else to offer it is the art of medicine that is crucial in addressing patient needs and compassion is the cornerstone of this. Hippocrates referred to medicine as an “art” in the Hippocratic Oath.¹⁹ We should use the art as much as applying the science to do what is right for patients. My mum intuitively knew this all along giving me one of the most important lessons in medicine outside of the medical school. And wonder of wonders the science is now proving that that smiling and being kind does make patients feel better.²⁰ Mum was right . . . again.

References

1. Robert Francis QC. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry.UK Stationary Office 2013
2. Paul Gilbert , The compassionate mind: a new approach life’s challenges. (Oakland:New Harbinger Publications 2010), 171
3. GiorgiaSilani, Claus Lamm, Christian C. Ruff ,Tania Singer. Right Supramarginal Gyrus Is Crucial to Overcome Emotional Egocentricity Bias in Social Judgements The Journal of Neuroscience 2013;33 (39): 15466-15476.
4. Sharon Palgi ,Ehud Klein, Simone G. Shamay-Tsoory,Intranasal administration of oxytocin increases compassion toward women.SocCogn Affect Neurosci. 2015;10(3):311-7.
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16. Paul Cassar , The holy infirmary of the Knights of St. John “La Sacra Infermeria” (The Mediterranean Conference Centre 1994), 1-60
17. George Sandys,A Relation of a Journey Begun an Dom. 1610. FoureBookes  accessed January 11,2016, https://books.google.co.uk/books
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