Hannah Gillespie is an Academic Foundation Year 2 Doctor in Northern Ireland. Her submission, ‘How can tomorrow’s doctors be more caring?’, was selected as the winner of the Research Paper Award at the ASME ASM in July 2019.
Many are motivated to become doctors because it is a caring profession. Medicine is, in that sense, a vocation. But in recent years, the focus of attention has changed from students becoming caring to students demonstrating professionalism. The General Medical Councils’ ‘Outcomes for Doctors’ details three domains that medical students must be able to demonstrate upon graduation – professional values and behaviours, professional knowledge, and professional skills. These domains mandate the minimum standards that students must adhere to in order to qualify as a doctor and care for patients. But despite this, doctors do not always act in caring ways. This begs the question: what is caring, and is the tradition of caring still relevant in the age of professionalism?
We set out to answer these questions. In doing so, our objective was to give patients a voice in education for caring. Edmund Husserl, father of contemporary phenomenology, exhorted philosophers to ‘return to the things [phenomena] themselves’. Rather than defining caring, or using existing professionalism frameworks to understand it, we sought to return to the phenomenon of caring itself by asking: How do patients experience doctors being (un)caring? We first reviewed all published literature in which patients, rather than professionals, had spoken of the essence of caring. We then asked patients themselves.
Patients told us that caring was, above all, genuine. Genuineness was ‘when your heart is in it’. ‘It doesn’t need to be a serious issue…they take you seriously.’ Caring was not ‘the cliched “Oh there, there, you’ll be alright”’. It was ‘real empathy, real engagement with an individual on their level’. Participants found this genuineness hard to describe. They ‘couldn’t just rattle off things; it’s just a comfort level and … little things you experience as you’re with a doctor [that]…decide it…’. Caring doctors didn’t ‘even have to think about going the extra mile, it just comes natural to them’. Being knowledgeable contributed to genuine caring: ‘It’s their knowledge…they have studied this to get their knowledge, to care for you…knowing that knowledge alone makes you caring.’
Patients experienced caring when: doctors allowed their own individuality to interact with patients’ individuality, engaged with patients to form relationships and communicate, and did little things that went ‘above and beyond’.
What does this mean?
One implication is that healthcare students should learn how caring is at once complex and simple. It is complex because caring cannot be standardised or reduced to a single behaviour. Yet, it is simple because caring is expressed in small things such as making eye contact, standing up and greeting a patient, picking up on silences, and acknowledging patients’ feelings.
There is a risk that brief simulated encounters that contribute to summative assessments will promote stereotyped behaviours, rather than caring. This may falsely reassure learners and teachers, reinforce a hidden curriculum of objectivity, and promote the display of caring acts rather than genuine caring. One implication, therefore, is that curriculum leaders should seek balanced opportunities for students to develop caring relationships alongside clinical competence. We suggest that curriculum leaders should give ‘little things’ as much emphasis as technical medical interventions. They should repeat relentlessly that neither competence nor caring is, alone, sufficient. Both are necessary and integrating the two into a genuinely caring medical identity should be every (student) doctor’s aspiration.
Since the award
In translating this work into practice, we suggest that educators should think critically about their curriculum – does undergraduate education in their institution encourage students to become caring or is it encouraging them to demonstrate (or pretend to be) caring? One way we promote the development of genuine behaviours is ensuring students have opportunities to develop caring relationships with real patients throughout their training.
Since this award, I have been working to give students the opportunity to learn to care for patients by working with clinicians caring for patients. In the last year, we have implemented pre-prescribing in Northern Ireland, enabling final year students to write prescriptions for real patients under supervision. To help students learn reflexively from this experience, we also piloted case-based discussions, facilitated by people with diabetes and healthcare professionals, to help students learn reflexively from prescribing insulin.
Hannah Gillespie @gillespie_hj
This work has been published as two papers, a scoping literature review and primary phenomenological analysis. These can be accessed at:
Gillespie H, Kelly M, Gormley G, King N, Gilliland D and Dornan T (2018) How can tomorrow’s doctors be more caring? A phenomenological investigation. Medical Education, 52: 1052-1063. doi:10.1111/medu.13684
Gillespie H, Kelly M, Duggan S, Dornan T (2017) How do patients’ experience caring? Scoping review. Patient Education and Counselling, 100 (9): 1622 – 1633. doi:10.1016/j.pec.2017.03.029