Can we teach compassion? CONTEXT The

Rich—what a guy!!!!
Can We Teach CompassionCompassion-A
Tribute to Rich Sarkin!
Sarkin!
Joseph O’
O’Donnell, MD
Dartmouth Medical School
Can we teach compassion?
The Three AmigosAmigos-wild and crazy guys
El Guapo and “we can sew”
sew”
Quotes from a stand up comic
Not everything worksworks-true confessions
H-I-P-P-A---sung
---sung to YMCA
Having fun in medical education
I love my wife and kids
CONTEXT
“The times are out of joint”
joint”
Shakespeare
What do you think?
The Sacramento Study
Compassion fatigue
Healing, wholeness, holistic---health
holistic----health
What are we doing?
The “Perfect Storm”
“If I can’
can’t see very far, it’
it’s because giants
are standing on my shoulders.”
shoulders.”
“When my income started to drop 10 years
ago, I just started going home at 8pm
rather than 7. I can’
can’t start going home at
9.”
9.”
Too much to know
Too much to do
Not enough time
Demanding consumers
Too much paperwork
Not enough money
Etc.Etc.-you name it.
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“Every system is perfectly designed
to get the results it gets”
gets”
He has no enemies, but he’
he’s
intensely disliked by all his friends.
Oscar Wilde
No wonder there’
there’s a compassion
fatigue!
Good seeds
Socialization for detached concernconcern-Fox
PrePre-cynical and cynical years
We eat our young
A cultural clash
Can we be raised in a greenhouse
rather than a hothouse?
Let 1000 flowers bloom!
Defoliants
Why can angels fly?
THESIS
We must attend to the education of
the heart and soul, like we do to
that of the head and hand.
Healing is in the presentpresent-so are
compassion and love
To achieve these requires connectionconnection-how
does our story intersect with their story?
These can be a product of the culture.
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Some ideas
Rita Charon
Rita Charon
Ned Cassem
Michael Kearney
Howard Gardner
Parker Palmer
Rachel Naomi Remen
Tom Inui
Matthew Kelly
“Write the history in the first person.”
person.”
The world isn’
isn’t made of atoms; it is made
of stories.
Everyone is a story.
Listen for the story
Perhaps by reading, writing, telling or
listening to stories carefully, we will be
able to read our patients (and colleagues)
better
“Everything is held together with stories.
That is all that is holding us together,
stories and compassion.”
compassion.”
Why would anyone in medicine
write stories?
•To remember
•To listen
•To learn
•To feel
•To survive
The parallel chart
Narrative knowledge
Barry Lopez, The Winter CountCount-1973
How does a person react to an event like this?
I had woken up in the morning never having seen a death,
but by lunchtime, I had been part of one. Nothing in medical
school or in life had prepared me for that moment. Amid
a jumble of predictable emotions-sadness, fear,
confusion, a certain excitement-I felt wrenchingly and
terribly alone. I had seen a heart stop, I had felt ribs break
under my thrusting palms. The people I loved best in the
world were not in medicine. Would they understand
what I had seen and done? Would I be inevitably separated
from them by this experience and those that would follow it?
I did the only thing I could think of. I sat down that
afternoon and wrote it all down. If I could tell my mother, my
brother, my friend in film school, exactly what had happened,
then I wouldn’t be alone. And maybe while trying to make
them understand, I would come to understand it too.”
EMILY TRANSUE, MD
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Space
somewhere back there someone said
“never sit on a patient’s bed
it’s an impolite invasion of their only space”
I heeded that advice for many years
and usually stood there awkwardly
apologizing for waking her
probably giving her some bad news
like you can’t go home today
or there is no cure
all the while respecting that private space
preserving the great divide
as the hair gets gray and gone
people tell me things
my being a family doctor they always have
but I’m talking about different things-not important clinical history, systems reviewed
positives and pertinent negatives
not the chief complaint, social history or past medical historythings about their life, not their health
things about their loves, not their pains
things about their secrets, not their surgeries
things about their fears, not their pills
things about their hopes, not their aches,
they sound like they’re talking to a friend
these things they’re talking about
they sound like they’re talking to an old friend
these things they’re talking about
and they’re friends I’m going to miss
when I finally have time to listen
Three sets of questions
AccomplishmentsAccomplishments-eg prowess in acting,
music, sports, awards won, rank in
military, status in neighborhood etc
Who is really important to themthem-eg who do
they love? Who loves them? Who are they
closest to?
What are their favorite things? Music,
books, newspapers, hobbies, sports
teams, restaurants?
lately many of the patients I see
are my friends, either dear or distant,
I always feel better
if I hold his hand
and, yes, sit on his bed
as we’re talking about things
very important to him.
his space may seem invaded to some
but we probably feel more connected
at a time
when we both need it.
8-10-95
Ned Cassem
Rescue your patient from the anonymity
that accompanies illness.
We work to connect our stories with theirs
The “connectional relationship”
relationship”
The Village WatchmanWatchman-Terry
Tempest Williams
“What is it really like to be inside your
body?”
body?”
“I can’
can’t tell you what it’
it’s like except to say
that I feel pain for not being seen as the
person I am.”
am.”
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THE WAY WE CARE CAN HELP
US REACH THE DEEPEST
PLACES
“Friendship of the heart”
heart”
A journey of accompaniment
“Each patient carries his own
doctor inside him. They come to us
not knowing that truth. We are at
our best when we give the doctor
who resides within each patient the
chance to go to work”
work”
Albert Schweitzer
The real presence of another person is a
place of security.
Michael Kearney
Pain versus Suffering
Eric Cassell
The Aescalapian model
Create a space for healing
Contain and hold
Witnessing
It’s all about meaning
Why?
The three stonecutters
Viktor Frankl
The Choice is YoursYours-a Ruth Drazen film
You CAN choose your attitude no matter
what
It’
It’s all about love and connection
Meaning fosters commitment
We need to educate for meaning
Most potent tool in the doctor’
doctor’s
armamentarium is the doctor him/herself
Attending to wholeness yields better
results
It feels good and is healthier
After all, we are in a healing profession
Mindfulness is above evidence based
medicinemedicine-phronesis
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A CULTURAL THING
How do we change a culture?
It is hardhard-cultures are broad, deep, and
stable
Medicine and medical school are cultures.
The process of enculturation is subtle but
strong
The heavy influence of the hidden
curriculum
Culture eats strategy for lunch
Culture……
Culture……
“shared values, assumptions, norms,
behaviors, rituals developed by a group as
well as the structures used to preserve
these essentials”
essentials”
How an Anthropologist Looks at a
Culture
Artifacts
Espoused values
Underlying assumptions
A fish cannot know water
The iceberg analogy
That’
That’s what we do here
DEC vs H-P
The Culture Code by Clotaire
Rapoille
Thesis: A single code word or phrase often
can capture the complex values,
assumptions and behaviors that make up
a culture.
The House of Medicine
Individualistic
Autonomous
Scholarly
Expert centered
Competitive
Focused
High achieving
Hierarchical
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What code words should describe
it?
Collaborative
Transparent
Outcomes focused
Mutually accountable
Team based
Service oriented
Patient centered
"I have only three enemies. My favorite one,
the one most easily influenced for
the better, is the British Empire. My second
enemy, the Indian people, is far
more difficult. But my most formidable
opponent is a man named Mohandas K.
Gandhi. with him I seem to have very little
influence."
THREE MARRIAGES
The person we love or are meant to love
Our work
Ourselves
We need to pay attention to all threethree-and
have courageous conversations about each
Parker Palmer
A Hidden Wholeness
Become divided no more
The Rosa Parks phenomenon
“I report to the land”
land”
Mohandas K. Gandhi
Some Highlights
Requires not being divided
Connect your stories
We learn this in school
New Professional “the internal change agent that
health care needs”
needs”
The logic of institutions is about selfselfpreservation; the logic of the human heart is
about love and duty
Learning to confront not collaborate with
institutional inhumanity
The undivided life produces the best of
practice, teaching, research
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Doing Good Work…
We need to challenge the belief that
institutions are external to us and
constraining upon us, as if they had
superhuman powers that render us
helpless.
Not “they”
they”, but “us”
us”
Howard GardnerGardner-Harvard School of
Education
What does this mean?
Where excellence and ethics meet
…Doing Good Work
What is “flow”
flow”?
Analagous to the “sweet spot”
spot”
Happens more at work than anyplace else
Parker Palmer
“WE WORK BEST WHEN THE HEART,
THE HEAD AND THE HAND WORK
TOGETHERTOGETHER-DOING “GOOD WORK”
WORK”,
REACHING “FLOW”
FLOW”, BEING “DIVIDED
NO MORE.”
MORE.”
Vertical and horizontal support: periods of
renewal
The Journey
One day you finally knew
what you had to do, and began,
though the voices around you
kept shouting
their bad advicethough the whole house
began to tremble
and you felt the old tug at your ankles.
“Mend my life!”
each voice cried.
but you didn’t stop.
You knew what you had to do.
The Journey (cont.)
…little by little,
As you left their voices behind,
The stars began to burn
Through sheets of clouds,
And there was a new voice
Which you slowly
Recognized as your own,
That kept you company
As you strode deeper and deeper
Into the world,
Determined to do
The only thing you could doDetermined to save
The only life you could save.
Mary Oliver
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Two Kinds of Intelligence
Rumi
Two Kinds of Intelligence
Two Kinds of Intelligence
There are two kinds of intelligence:
One acquired, as a child in school
memorizes facts and concepts from
books and from what the teacher
says, collecting information from the
traditional sciences.
With such intelligence you rise in the
world.
You get ranked ahead or behind others
in regard to your competence in
retaining information.
You stroll with this intelligence in and
out of fields of knowledge getting
always more marks on your preserving
tablets.
Two Kinds of Intelligence
Two Kinds of Intelligence
There is another kind of tablet, one
already completed and preserved
inside you.
A spring overflowing its springbox.
springbox.
A freshness in the center of the chest.
This other intelligence does not turn
yellow or stagnate. It’
It’s fluid, and
doesn’
doesn’t move from outside to inside
through the conduits of plumbingplumbinglearning.
This second knowing is a fountainhead
From within you moving out.
Rumi
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Traits of Colleagues who Stay
Joyful…
Humor
Strong support
Clear values
Openness to patient’
patient’s gifts
Collegiality
Focus on what is true rather than what
is beautiful
The Secret is…
is…..
The HokeyHokey-Pokey
That’
That’s what it’
it’s all about!!!
What is the “happy life”?
The Pleasant life
– Positive emotions buffer the negative
Not Hollywood smiley faces
The Engaged life
The Meaningful Life
THE FULL LIFE (all three)
– Seligman
The Healers Art
A “different”
different” course
Spreading like wildfire
Rejuvenating for both faculty and students
Discovery model, climate of safety, radical
listening, no right answers
Developing a community
It’
It’s “bullet proof”
proof”
Wholeness
IntroductionsIntroductions-who are these people?
Seed talktalk-shadow
ExerciseExercise-what is in your shadow?
Debrief
ClosingClosing-wishing others well
SHADOW
Culture can wound, but culture can heal.
What is it that’
that’s in our shadow? How can
we bring it to the bedside of a sick patient?
It’
It’s the same stuff at multiple schools!
I am enough!
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There's a neighborhood song that is meant for the
child in each of us and I'd like to give you the
words of that song right now.
"It's you I like.
It's not the things you wear.
It's not the way you do your hair
But it's you I like.
The way you are right now
The way down deep inside you.
Not the things that hide you.
Not your caps and gowns,
They're just beside you.
But it's you I like.
Every part of you.
Your skin, your eyes, your feelings
Whether old or new.
I hope that you remember
Even when you're feeling blue.
That it's you I like,
It's you, yourself
It's you.
It's you I like."
Dealing with Grief and Loss
And what that ultimately means, of course, is that
you don't ever have to do anything sensational
for people to love you. When I say it's you I like,
I'm talking about that part of you that knows that
life is far more than anything you can ever see or
hear or touch. That deep part of you that allows
you to stand for those things without which
humankind cannot survive. Love that conquers
hate, peace that rises triumphant over war, and
justice that proves more powerful than greed.
Fred McFeely Rogers
It is part of life.
We have pretty dysfunctional ways of
dealing with it
What have been our experiences with how
it has been done?
Doing it well heals our hearts and helps
prevent numbness and burnout.
“Feely hearts”
hearts”
Beauty, Awe and Wonder
Medicine is as full of mystery as it is of
mastery.
We need to train ourselves to notice.
What surprised me today? what motivated
me today? What inspired me today?
“Small good things”
things”
We need to effectively deal with grief and
lossloss-or else we close our hearts and
become numb
We need to be open to beauty, awe,
wonder, mystery and moments of grace.
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RECLAIMING THE SOUL
APPRECIATIVE INQUIRY
Our business is service
Service vs helping or fixing
Rewriting our own Hippocratic oath
Who are these people I’
I’ve been teaching
or in class with?
How do we have that courageous
conversation about our work?
Instead of what is wrong, ask what works?
Transforming culture of professionalism at
Indiana University and other schools
Immersion conferences
APPRECIATIVE INQUIRY
In every society, organization or group,
something works
What we focus on becomes our reality
Positive visions are most likely to create
positive futures.
The act of asking questions of an
organization or group influences the group
in some way.
The language we use creates our reality
APPRECIATIVE INQUIRYINQUIRY-A
FOCUS ON “WHAT WORKS”
WORKS”
Discover
Dream
Design
“We see what we look for and we miss
much of what we are not looking for even
though it is there... Our experience of the
world is heavily influenced by where we
place our attention.”
Stavros and Torres
DISCOVERY PHASE
Tell a personal story about a time when
you really experienced compassionate
care in your work.
Listen to the stories of others
What are the themes?
Deliver
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DREAM PHASE
Suppose you went to sleep and woke up
to go to a perfect workplace where high
levels of competence and compassion
were present? What would it look like?
How would people treat each other? What
would it feel like?
Start by checking in.
How are you doing?
Notice the culture
Try appreciative debriefdebrief-what was an important
point for you in the meeting we just had?
Maybe that IS the work.
Empower people to dream
The End of the Hematology Course
Slides by Robert Pope
Music by Judy Collins
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An Exercise
What do you see medically?
Morally?
Spiritually?
What is grace and when is it present in
healthcare?
What does it mean to be present?
Can we aim to teach this? Can we create
the environment/culture that fosters this?
How can it gain “respect”
respect”?
Pebbles in the pond or seedlings in a
boulder
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All you have to do is dream…..
We must teach people to show
up
The Dream Manager by Matthew Kelly
Go to the employees
Everyone has dreams
What are yours?
The head bone is connected to the
heart bone. Don’
Don’t let them come
apart.
Hawkeye Pierce
REMEMBER: MEDICINE IS THE
MOST SCIENTIFIC OF THE
HUMANITIES AND THE MOST
HUMANE OF THE SCIENCES.
Take Homes
Notice your culture
Show upup-all of “you”
you” (head, heart, hand , soul)
Live “divided no more”
more”
Do good workwork-experience flow
Have courageous conversations
Remember the world is made of stories
Recognize beauty, awe, wonder, mystery and grace
Create a space for healinghealing-contain and hold
Rescue patients from the anonymity that accompanies illness
Try appreciative inquiry
Dream!!!!
THANK YOU!!!!!!
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