COMPASSION AND SELF-COMPASSION IN MEDICINE

Full text

Compassion and self-compassion in medicine: Self-care for the caregiver
Jason Mills,1 Michael Chapman2
1. Faculty of Nursing and Midwifery, The University of Sydney
2. ANU Medical School, Australian National University
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[AMJ 2016;9(5):87–91]
EDITORIAL
Please cite this paper as: Mills J, Chapman M. Compassion and
self-compassion in medicine: Self-care for the caregiver. AMJ
2016;9(5):87–91. http://dx.doi.org/10.4066/AMJ.2016.2583
Corresponding Author:
Jason Mills
PhD Candidate, Faculty of Nursing and Midwifery
The University of Sydney
MO2 Mallett St, Camperdown NSW Australia
Email: jmil4489@uni.sydney.edu.au
Introduction
Combining medicine and compassion means
resolving to cultivate compassion—the will to ease
suffering—in order to benefit your patients.
Compassion and loving kindness are the basic
factors that create harmony and wellbeing for
ourselves and others.1
In a Lancet article several years ago, physician wellness was
highlighted globally as a missing quality indicator–in the
context of widespread self-neglect and ill-health.2 Now in our
region the health and wellbeing of doctors are topics of
growing interest. Both were discussed as essential to safe and
effective medical practice at the recent Australasian Doctors’
Health Conference.3 While the provision of staff support and
doctors’ health programs are imperative; so too, is effective
self-care. By this, we mean actively taking care of oneself.
It has now been a decade since the publication of Keeping the
Doctor Alive,4 but there is a clear need for further work in this
area.5 In this paper, we suggest such work could usefully
explore doctors’ self-care in relation to their feelings of
compassion for themselves and for others. After all, how well
can doctors care for patients or themselves, if they lack such
compassion?
In the words of the 14th Dalai Lama, an esteemed scholar
of compassion:
For someone to develop genuine compassion
towards others, first he or she must have a
basis upon which to cultivate compassion, and
that basis is the ability to connect to one’s own
feelings and to care for one’s own welfare. . .
Caring for others requires caring for oneself.6
The importance of self-care
Whilst not unique to medicine, doctors working in this
profession appear at risk of stress and burnout.
Apart from doctors’ personal stressors, exposure to
patients’ pain and suffering is a normal feature of clinical
practice.7,8 Traditionally, many doctors have worn the
signs of ‘burnout’ as a badge of honour.9 But many argue
the impact of stress can compromise the compassionate
care provided to patients in addition to its effect on the
doctor’s well-being.8-10 Unfortunately there is evidence to
suggest that anxiety and depression are common, and the
suicide rate of doctors has been found to be higher than
in the general population.5
Consideration must also be given to social factors
influencing the therapeutic relationship between doctor
and patient.11 In the context of health professionals’ role
as exemplars for health promotion - patients may be less
likely to take medical advice seriously, if it seems
incongruent with their doctor’s own actions. Medical
advice about patients’ self-care could be seen as
hypocritical, if self-care isn’t in some way modelled by
doctors.12 Negative role modelling from doctors’
behaviour can also affect the training and well-being of
medical students.13 Exposure to self-destructive
behaviour (such as cynicism or poor self-care) through
supervising doctors is a potential contributor to the high
rates of stress, depression, and burnout among medical
students.5,13,14 The practice of self-care, then, may be
essential for medical practitioners and those around them
such as patients and students. In theory, self-care is not
complex; it’s simply about looking after one’s own health

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and wellbeing. In practice however, this may prove
challenging for some doctors-and demands congruence with
self-care advice given to patients. Self-care involves various
strategies that help promote or maintain ones’ physical,
mental, emotional, and spiritual health; as well as ensuring
that personal or family needs are not neglected.4 Self-care
also requires self-reflection and awareness to identify relevant
stressors and supports in both personal and professional
spheres. But to what extent can doctors effectively attend to
self-care, if they lack self-compassion?
The importance of compassion and self-compassion
Self-compassion involves extending the same compassion to
oneself as would be given to others. In this way self-
compassion does not denote a narcissistic self-interest. As a
construct, self-compassion has been conceptualised to
comprise self-kindness, mindfulness, and a sense of common
humanity.15 Importantly, self-compassion and its elements can
be learned. A suite of resources (including a self-test version
of the validated self-compassion scale) as well as self-
compassion exercises are freely available from Dr Kristin Neff
(http://selfcompassion.org/), co-author of the Mindful Self-
Compassion Program. Results from a randomised controlled
trial of this program indicate that mindfulness, self-
compassion, and wellbeing can be enhanced in the general
community.15
There is also a growing body of literature on self-compassion
in health care professionals, highlighting its benefits to
clinician’s wellbeing and its potential to enhance
compassionate care for patients.16-18 However, little is known
about self-compassion in doctors, as there has been scant
research into the medical workforce. While being self-critical
and perfectionistic may be common amongst doctors, being
kind to oneself is not a luxury; it is a necessity.19 Self-care is, in
a sense, a sine qua non for giving care to others-and it may be
that for doctors, as is the case in other populations, self-
compassion relates to compassion for others.20,21 Further,
investigations into possible correlations between doctors’
self-compassion and self-care, or compassion for others are
required and need to be based on an understanding of
compassion itself.
According to Cassell,22 compassion as a positive emotion is
vital to the practice of medicine. But compassion is more than
just kindness. It involves cognition, affect, intention, and
motivation; that in a context of suffering, relate to the
alleviation of that suffering.23 A recent study of patient
perspectives has defined compassion as ‘a virtuous response
that seeks to address the suffering and needs of a person
through relational understanding and action’.24 In clinicians,
some might argue a preference for competence over
compassion, but these are increasingly seen as
inseparable qualities.1,22-26 Expressing compassion in
clinical practice is, however, a complex endeavour which
may either influence or be influenced by a variety of
intrinsic, extrinsic, and organisational factors during any
given interaction.26 An appraisal process is also involved in
compassionate responding, and might be evident in
patient care when a doctor either consciously or
otherwise gauges whether they consider a patient to be
deserving of compassion.22 In the same way, compassion
for oneself can be absent if this appraisal results in
judgement or self-disparagement. Yet, compassion is
necessary. Even for unappreciative or ‘difficult’ patients,
and doctors who, of course, are only human.
Distinguishing between compassion and empathy
For compassion to be expressed more freely, greater
clarity of what compassion is and a deeper understanding
of how to educate for compassion will be required.22
A frequent issue complicating the understanding of
compassion is its conflation with empathy. These terms
are often used interchangeably and while both represent
other-focussed concern and are important for medical
practice, there are important distinctions. Empathy
relates to an awareness of another’s experience be that
pleasant or otherwise; whereas compassion relates
specifically to contexts of suffering and the alleviation of
it. Moreover, one’s empathy in response to others’
suffering could be a source of distress and inaction, if this
empathy is not accompanied by a compassionate wish to
act. This has been supported by research into functional
neural plasticity through the use of functional magnetic
resonance imaging (fMRI), where findings from multiple
studies suggest that increasing compassion may
reflect a new coping strategy to overcome empathic
distress and strengthen resilience.27-29
This highlights the misunderstanding of these two
capacities in the common use of the phrase compassion
fatigue, which as a construct is now widely measured in
health professional populations. It is seemingly empathy
that fatigues, and distances clinicians from their patients
and the best care that they can provide. Compassion is
better understood as a potential therapeutic intervention
for such fatigue. To overcome conflation with empathy,
and to enhance both patient care and the wellbeing of
doctors, a greater understanding of compassion is
required in medical education and practice. This could be
achieved through an explicit curriculum that educates

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medical students about compassion, and prepares them
experientially for compassionate practice.
Educating for compassion and self-compassion
The Healer’s Art is an innovative course taught at the
Australian National University to help restore the humanity in
medical education.30 Importantly, educational initiatives such
as this emphasise the ‘art’ of compassion, but we argue that
understanding the science of compassion is equally important.
A scientific basis for understanding compassion can help to
clarify misconceptions, inform education, and enhance its
application to clinical practice. It may be important, for
instance, to understand whether compassion levels in
students are enhanced throughout medical training—or if
compassion decreases over time, as with the so-called erosion
of empathy.31 Establishing an empirical evidence base will be
necessary to address questions like these. The use of validated
measures in longitudinal research designs will be required to
inform medical education and practice. Sir David Haslam,32
Chair of the UK’s National Institute for Health and Care
Excellence (NICE), argues ‘compassion needs to be nurtured
and retained, or it will very soon wither on the vine.’ Indeed,
public expectation might be that medical students should
become more compassionate as they progress through
training. Whilst this is yet to be established empirically, there
is growing evidence to suggest that compassion can be
cultivated.33,34
The Stanford University School of Medicine’s Compassion
Cultivation Training (CCT) protocol is one example. In a
randomised controlled trial involving community participants,
CCT resulted in significant improvements in self-compassion
and compassion for others.33 Further analyses indicated that
CCT also increased mindfulness and happiness, whilst
decreasing worry and emotional suppression.23 It has been
argued that compassion contributes to the wellbeing of self
and others, and there is now growing evidence to suggest the
cultivation of compassion and self-compassion might have
important implications for health and wellbeing. Previously, in
an undergraduate sample, compassion-specific meditation
was found to be associated with innate immune responses to
a psychosocial stressor.35 A more recent study has suggested
that self-compassion may serve as a protective factor against
stress-induced inflammation and inflammation-related
disease—even when controlling for self-esteem, depressive
symptoms, demographic factors, and distress.36 However,
there has been scant research into this area involving either
medical students or practitioners. Although the benefits of
mindfulness have been highlighted, including its links to
compassion and self-compassion, a significant barrier to
mindful practice has been its absence from medical training.19
Integration of mindfulness practices within some medical
curricula has produced positive outcomes for student
wellbeing,37 although direct assessment of self-care and
self-compassion have been limited to date. CCT has
recently been introduced to medical students at the
University of Melbourne,38 but in the absence of reported
outcomes, research is required to investigate its utility
and evaluate the effectiveness of cultivating compassion
in a medical student population.
An agenda for education, practice and research
Caring for others whilst neglecting oneself is neither
safe, nor sustainable for the practice of medicine. To this
end it is only logical that doctors’ self-care supports
patient care. As Kearney and colleagues39 state:
‘Self-care enables physicians to care for their patients in a
sustainable way with greater compassion, sensitivity,
effectiveness, and empathy.’ Similarly, it has been argued
that genuine compassion for others requires compassion
for oneself.6 Compassion is not an ‘optional extra’—and it
needs to be valued more in health care.32 Medical
education, it seems, does not yet adequately prepare
doctors for the ongoing challenge to discern and achieve
a balance between these. For medical students—and the
profession itself—to flourish in Australia, a ‘culture of
compassion’ is sorely needed, in place of a traditional
culture that has been punctuated by mistreatment of
medical students and teaching by humiliation.40
As highlighted by Haslam at NICE,32 it is compassionate
leadership that creates compassionate organisations and
culture change. However, the medical profession is not
alone in facing this challenge. Other health professions,
including nurses, have identified and already begun to
take up this research agenda to support clinical practice
and enhance patient care.17 This common ground
provides an opportunity for collaboration towards shared
goals and, through this, advances can be made in
interprofessional education. Scientific study of the
balance between compassion and care for self and others
presents a new perspective for research into clinicians’
self-care. From this perspective, there is opportunity to
gain an empirical understanding of the relationship
between these variables in clinical practice, and how they
might enhance the health and wellbeing of clinicians and
benefit patient care.
Whilst essential to the practice of medicine, discussion of
compassion, self-compassion and self-care is extremely
limited; where discussion does exist it relies largely upon
polemics as its basis, rather than empirical evidence.
To benefit both clinicians and patients, systematic

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research is needed to guide medical education and clinical
practice. Both quantitative and qualitative research designs
will be necessary in answering the important questions facing
doctors; in how they might better care for themselves, each
other, and ultimately, their patients. Future research might
usefully focus on biomarkers and use of neuroimaging such as
fMRI to overcome the limitations of previous studies that have
relied solely on self-report measures of compassion; and were
therefore potentially influenced by social desirability bias.
Whilst compassionate care is a shared goal, it may be
important to gain a nuanced understanding of self-care
practices and the expression of compassion in the context of
individual health professions. To this end, the development of
a Transactional Model of Physician Compassion26 addresses
compassion from the medical perspective, but it remains
unclear whether the expression of compassion or self-
compassion in other professions can be understood in the
same way. That there has been scant research into these
areas limits clinical practice, medical education, and
potentially compromises the preparedness of future doctors.
A robust and stepwise research agenda is therefore needed:
First, to examine any relationship between doctors’ self-care,
self-compassion, and compassion for others; second, to
determine how these can best be cultivated; and finally, to
investigate ways in which they might enhance clinical
outcomes and the care recipients’ experience of patient care.
In this way, medical education can draw upon empirical
evidence to prepare tomorrow’s doctors to better care for
themselves and their patients, with genuine compassion.
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CONFLICTS OF INTEREST
The authors declare there are no conflicts of interest.
FUNDING
None
ETHICS COMMITTEE APPROVAL
Not applicable.