Compassionate resilience in medical education

Dr KE Leedham-Green

• Wellbeing vsburnoutResilience

• Compassion vsdetachment

Quality of caring

• Safety vsinattention

Quality of care

• Withdrawal, disengagement

• Avoidant coping: e.g.alcoholUnhealthy

• Survival tactics e.g. TV, books

• Destructive if habitualUnsustainable

• Mindful practice

• Compassionate resilience

• Constructive engagementHealthy

Responses to stress

Epstein, 2014

The good, the bad and the resilient…

Positive values

• Service

• Altruism

• Knowledge

• Caring

• Empathy

• Competence

The dark side

• Over-commitment

• Perfectionism

• Hiding errors

• Need for certainty

• Personal distress

• Distancing

• Neglecting self

Compassionate resilience

• Balance

• Knowing limitations

• Engagement

• Compassionate action

• Gratitude and appreciation

• Self-care

• Self-compassion

• Reflective self questioning

Epstein, 2014

After you – you

look exhausted!

(compassion)

I can understand why

everyone is pushing

(empathy)

That poor

woman

(sympathy)

We shouldn’t

push (moral

reasoning)

What do we mean by compassionate resilience?

Don’t push!

I just don’t

care anymore

(burnout)

I will be late if I

don’t get on this

train (distress)

Well, everyone else

is pushing so why

not me? (poor role

modelling)

No-one is watching me

and I’ll never see any of

these people again

(disengagement)

The environment, burnout, distress, disengagement and poor role

modelling make compassionate care harder to achieve.

• Becoming a competent, confident, communicative, compassionate, caring doctor

Self-actualisation

• Feedback, progression, achievement, feeling challenged, making a difference

The need for self-esteem

• Longitudinal relationships with peers, teachers, places, patients

The need for love/belonging

• Sufficient control over areas of responsibility, fair assessment, sufficient resources for all

The need for security

• Sleep, food, exercise, time for self-care

Physiological needs

Adapted from Maslow, 1954

How resilient do you feel?

Go vote

Go to www.govote.at and use the code 10 29 26

EPSTEIN’S 5 HYPOTHESES OF COMPASSIONATE RESILIENCE

Compassion requires resilience – to be ‘present’ with suffering

Compassion for others is facilitated by compassion for oneself

Resilience is a capacity that can grow

Wellbeing is about engagement not withdrawal

Mindful practice is a group activity

The new curriculum

• Emphasis on

– Primary care

– Psychological health

– Long-term conditions

– Health promotion and disease prevention

• Longitudinal relationships

– Clinicians, places, peers, patients

Critical thinking exercise– What questions do we

need to ask?– What are some ideas for

addressing that?• What is the evidence• What else might work• What are the potential

issues with that?

– What next?

How can I make this happen?

– Who, what, when by, how

Workshop activities

3 Scenarios1. The clinical workplace

learning environment2. Self-care and

compassion3. Mindful practice

Clinical workplace learning environment

Scenario 1“I don’t think I could work here. Everyone seems so stressed and grumpy. How could I balance this level of work with my other goals in life, such as starting a family? I want to make a difference to my patients, this just feels like tick-box medicine with QOF being the only outcome that matters.”

Personal control?Teamwork?

Environment?Workload?

Critical thinking exercise– What questions do we need to ask?– What are some ideas for addressing that?

• What is the evidence• What else might work• What are the potential issues with that?

– What next?

How can I make this happen?– Who, what, when by, how

Self-care and compassion

Scenario 2

“I’ve failed my formative OSCE. I worked so hard, I must be useless. I couldn’t sleep last night and the coffee machine’s not working. I’ve had enough, I feel so low, I’m going home to get drunk.”

Recognising moments of vulnerability?

Providing peer support?Modeling self-care?

Appreciative enquiry?

Critical thinking exercise– What questions do we need to ask?– What are some ideas for addressing that?

• What is the evidence• What else might work• What are the potential issues with that?

– What next?

How can I make this happen?– Who, what, when by, how

Mindful practice

Scenario 3

“I was so busy trying to get through everything that I didn’t notice what was really going on with that patient. I’d like to talk about it with someone but I’m too embarrassed. I don’t think it shows me in a very good light.”

Recognising and discussing emotions

Noticing and actingSlowing at critical momentsHonest, attentive reflection

Critical thinking exercise– What questions do we need to ask?– What are some ideas for addressing that?

• What is the evidence• What else might work• What are the potential issues with that?

– What next?

How can I make this happen?– Who, what, when by, how

Conclusions and take-home messagesThank you

kay.leedham-green@kcl.ac.uk

Clinical workplace learning environment audit

Measuring the learning culture of the clinical workplace

Jennifer Newton, Brian Jolly, Amanda Henderson

http://www.ncbi.nlm.nih.gov/pubmed/25064265

Incorporates student and staff perspectives.

Likert scale domains:

• collegiality,

• teamwork,

• being valued,

• respect,

• university values (orderly structure, knowledge generation, critical reflectiveness)

• workplace values (efficiency, doing the work, patient outcomes, orderly chaos)

Example questions

• ‘Staff help each other to get the job done’

• ‘Changing practice in this workplace is difficult’

• ‘It is clear that my work is important to the success of this workplace’

• ‘People consider colleagues’ feelings’

• ‘I am encouraged to try new things’

• ‘Workload allocations are carefully planned’