To be the best healers possible for others, we have to show compassion for and take care of ourselves.
I wrote a previous article published in KevinMD titled, “Self-care is not selfish: It’s imperative to save the practice of medicine.”
Self-care includes doing no harm to yourself.
During our medical training, many habits and thought patterns were deeply ingrained. These thought patterns, while they may have been helpful in getting us into medical school and through our rigorous training, are also unhealthy and actually often cause us harm. Accepting dangerous levels of sleep deprivation and living with minimal time for rest, recovery, and connection with family are just a few examples of behavior patterns that cause harm to physicians. A few others include perfectionism, judging, blaming, and shaming ourselves.
Ahimsa is a concept I learned in yoga teacher training. In Sanskrit, “ahimsa” means non-injury. In the Indian religions of Jainism, Hinduism, and Buddhism, ahimsa is the ethical principle of not causing harm to living things.
Ahimsa is different from the original Hippocratic Oath most of us took as we graduated from medical school in that it emphasizes the importance of doing no harm to yourself.
Ahimsa also dictates that it is not just physical harm but also emotional harm.
In 2017, the World Medical Association approved an additional clause to the Hippocratic Oath that states “first do no harm.” The addition reads: “I will attend to my own health, well-being, and abilities in order to provide care of the highest standard.”
When I trained, albeit 25 years ago, we were not taught to include ourselves explicitly in the “do no harm” tenet. We were also not taught how to respond to mistakes, perceived mistakes, and unexpected outcomes in ways that did not cause harm to us as physicians.
In 2021, we still have a long way to go to support physicians in responding to mistakes and unexpected outcomes in ways that honor both patients’ suffering and physicians’ own humanity. I currently work as a coach for anesthesia fellows at a prestigious university. I see through my work with the fellows that the culture of medicine still does not generally encourage physicians to show themselves grace and compassion and practice ahimsa. Many physician suicides appear to still be triggered by mistakes, perceived mistakes, unexpected outcomes, and the shame, blame, and guilt that often results.
We all wish that mistakes and unexpected outcomes would never happen. Because physicians are human and our patients are human, they will continue to happen.
What can we do to spare ourselves and our colleagues harm as we practice medicine from the heart?
How can we create a culture of medicine where we treat ourselves and each other with grace and compassion?
What if physicians could acknowledge and accept our perfectly imperfect humanness?
Asking ourselves the question, “What would compassion do?” is a helpful place to start.
This question opens the mind up to learning and growth rather than shame and blame.
The compassion being asked about is for you, first and foremost, as well as this patient and all your future patients.
This compassion also often includes colleagues involved in the case and your loved ones and family at home who are experiencing the event alongside you, whether they know it or not.
The key component to the effectiveness of this question is to consider what compassion would do for you as the physician who almost always “did the best they could with the information they had at the moment.” I find that adding this phrase helps many physicians I work with begin to grow compassion for themselves in the face of unexpected outcomes.
“Unlike self-criticism — which asks if you’re good enough, self-compassion asks what’s good for you.” – Kristin Neff, PhD.
What’s good for you as a physician is also good for your patients. If you are not well or are struggling with blame, shame, and guilt, your patients are impacted.
“Self-compassion provides us the life raft we need to navigate through tough times. By deepening self-compassion, we discover untapped reserves of strength and resilience and wisdom that help us survive the storm–and we strengthen our resources to better navigate future storms.” – Shauna Shapiro, PhD, “Good Morning, I Love You: Mindfulness and Self Compassion Practices to Rewire Your Brain for Clarity and Joy”
We are experts at showing compassion for others — our patients, loved ones, and even colleagues. We rarely extend this same treatment to ourselves.
Showing ourselves compassion is frequently seen by physicians as self-indulgent in medicine. We fear that if we are not mean to ourselves, we somehow are not being “responsible” or caring adequately for others. I offer that there is enough compassion for everyone involved in an unexpected outcome in medicine to show compassion for everyone involved and that in doing so, we contribute to the betterment of all the individuals involved and medicine.
It is common for physicians to hold themselves to unattainable expectations. When we inevitably fall short, we feel shame. Feeling shame makes it hard to learn and grow, which is exactly what would help our future patients and us as physicians the most.
Mindfulness and self-compassion as an alternative response change our neural connections and make it easier for us to learn and grow from difficult experiences.
“Shame robs our brain of the resources it needs to respond directly to the challenging situation …. When we feel shame, the amygdala, the part of our brain that is central to memory decision-making and emotional responses, triggers a cascade of NE and cortisol chemicals that increase our cortisol level, narrow our perspective on perceived threats and inhibit our cognitive flexibility… If we want to learn from our mistakes and keep from repeating them, we need a compassionate mindset, not shame.”
–Shauna Shapiro, PhD, “Good Morning I Love You: Mindfulness and Self Compassion Practices to Rewire Your Brain for Clarity and Joy”
I work with a physician who is a “quality lead” in a large academic emergency department. Interestingly it is “easy” for her to show compassion for her colleagues during quality case reviews. She almost always believes that “her colleagues are smart and did their best to provide the best care they could.” She sees their case reviews as learning and growth opportunities. She rarely sees them as failures or anything of which anyone should be ashamed.
When a case review involves a question about her own care, however, she immediately turns to self-judgment and shame. “What did I do wrong?” “What did I miss?” or “Did I make a mistake?” As the quality lead, she feels it is necessary to hold herself to an even higher standard than her colleagues. This is not uncommon. We so often grant compassion to others that we are unable or unwilling to show ourselves.
What if all our quality leads could become models of self-compassion, curiosity, and ahimsa (do no harm) in the face of their own perceived shortcomings?
What could change in the culture of medicine as a result?
What if every physician practiced ahimsa and approached the challenges inherent in practicing medicine in a mindful way. It would invoke more kindness, curiosity, growth, and learning.
We as physicians will benefit, our patients will benefit, and the practice of medicine will benefit.
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