The following quote and text is an excerpt from a chapter of a Royal College of General Practitioners’ publication: Compassion, Continuity and Caring in the NHS; out now. This is a celebration of over 65 years of the RCGP and its motto ‘Cum Scientia Caritas’, edited by Rodger Charlton, the honorary editor of RCGP publications.
‘When In 1922, on the very morning after I had graduated I plunged straight into general practice armed with a thermometer and a stethoscope, and precariously buoyed up with faith, hope and charity — faith in whatever knowledge I had succeeded in acquiring from my excellent teachers, hope that I should remember the dose of strychnine and which forceps blade to insert first, plus my inborn but, so far, undeveloped caritas.’
This was GL McCulloch speaking in 1969 to the East Anglia RCGP faculty about the RCGP’s motto, Cum Scientia Caritas.1 The college and its motto (‘Science with Compassion’) will be celebrating its 65th anniversary next year. How times have changed since McCulloch was practising.
For me, in 2013, on the morning after I had registered as a fully-qualified GP (7 years after graduating from medical school), I plunged straight into general practice armed not with a thermometer but a smartcard. Although I too was buoyed up with faith and hope, my faith was in Google and BNF Online, and my hope was that as the only male GP at the practice I wouldn’t be called on to do too many smear tests.
But what about my caritas? I had certainly learned the techniques: I was asking about ideas, concerns, and expectations long before I could take blood or write a prescription, and I had later learned the value of connecting with patients so convincingly described by Roger Neighbour.2 To any observer, or Clinical Skills Assessment examiner, I was a caring, compassionate doctor. But inwardly, did I experience a ‘feeling with’ my patients that would allow me to see them as something more than a piñata to be hit in such a way that their symptoms fall out in a form that I could apply my accumulated knowledge to?
Now that we have a better understanding of disease and more effective treatments, our patients are less obviously suffering (at least physically) than they were in the 1920s where there:
‘... was almost no science at all … We had opium and morphia and caritas.’ 1
As we have become more scientific have we become less compassionate? McCulloch argued that his junior colleagues, in unnecessarily investigating patients rather than acknowledging and addressing their suffering, were depriving them of their martyrdom badge. The bottles of brightly-coloured and hideously-flavoured medicine that McCulloch dispensed were the martyrdom badge that they required to gain ‘that sympathy of which they have been starved’.1 He went on:
‘... whatever these things contain, our giving them to the patient, short of poisoning him, is good therapy. Indeed, nowadays they are an absolute necessity.’1
Should we find room for the martyrdom badge in a world dominated by evidence-based medicine? If prescribing drugs that we know are little more than placebos helps to provide a compassionate rather than scientific response to patients’ circumstances, might this not be such a bad thing?
HAVING THE TIME TO CARE
Recently a patient thanked me as she was leaving my consulting room and said that I was a compassionate doctor. I was at once flattered, wary, and confused. Confused as I felt I’d done little in the consultation apart from sit opposite her, nod my head, and reflected back to her some of what she’d said. I didn’t recall feeling moved by her problem, or saddened by her suffering. I felt that I wanted to help her with her problem and I had the means to do so thanks to years of training, a reasonable night’s sleep, and an empty bladder. But there was one other key ingredient that allowed me to behave in a compassionate manner: time. For however we define compassion, either as a feeling or behaviour, we know that in a 10-minute consultation it rarely gets the chance to emerge.
Compassion requires time. Time to listen, time to explain, time to let someone finish telling his or her story, time to offer sympathy rather than antibiotics as a martyrdom badge, time to look up the evidence, time to let the tears dry, time to think, and time to clear your head before the next patient. When we’re overworked and have no time we stop feeling and stop acting compassionately.
In project management there is a useful rule to aid time management: the 60:20:20 rule.3 That’s 60% of time allocated for planned work, 20% for unplanned work and 20% for socialising. What a difference to compassion and caring would it make to use these ratios in general practice?
Where I work we undoubtedly fall short of this standard but we offer 15-minute appointments and try to find half an hour a day to have lunch or a chat with each other. It seems to work.
As the motto Cum Scientia Caritas is soon to reach its 65th birthday, perhaps it’s time for it to retire and be replaced by a motto we can all understand: Science with Time.
- © British Journal of General Practice 2016