Schwartz Rounds: reviving compassion in modern healthcare

Expectations of modern healthcare are extremely high. Medicine can achieve wonders hardly dreamt of 50 years ago. Technology and the accelerated pace of change threaten to displace compassion. That old phrase which used to resonate when used by consultants on ward rounds, ‘lots of TLC, Sister’ is rarely heard now. Healthcare is expensive and every nation wrestles with its priorities and problems. The urge to measure is understandable and necessary and has led to positive results such as the marked reduction in waiting times for treatment in hospital within the NHS. And yet, much of what is really valuable to our patients is difficult to measure. Prompted by our Director of Nursing and supported by King's Fund we have embarked on the Schwartz Rounds.1 The Royal Brompton and Harefield are the third hospital Trust in the UK to do so after Cheltenham and Gloucester and the Royal Free Hospitals. As a postgraduate teaching institution, the Royal Brompton and Harefield NHS Foundation Trust aspires to care, at the highest level, for patients with heart and lung disease. We endeavour to manage difficult clinical problems that others cannot. In this process it is easy to get lost in the logistics of efficiency and innovation and to ignore the human relationships that develop between both staff and their patients and between different staff members. Ken Schwartz was a successful American lawyer in his early 40s when he was struck down with lung cancer. He was treated at the Brigham and Women's Hospital, Boston some 11 years ago. Despite all attempts at treatment he died 11 months after the initial diagnosis was made. He and his family had nothing but praise for the care he received at an internationally renowned centre. They realized also the importance of their relationships with the caregivers. Indeed, in an essay in the Boston Globe, Ken Schwartz wrote that ‘the smallest acts of kindness made the unbearable bearable’. The family set up a legacy to enable monthly meetings, Schwartz Rounds, to take place where individual staff members could feel free and safe to express and understand their feelings about the care of a particular patient. The Rounds aim to nurture the relationships between patients and all members of staff within an institution. Everyone is welcomed to the Schwartz Rounds – porters, catering staff, pharmacists, librarians, scientists, managers and administrators. It is not just for doctors, nurses and therapists. Many of us were brought up in an age when the metaphorical stiff upper lip still held sway. While we were allowed to have ‘feelings’ we were discouraged from ‘wearing them on our sleeve’. As busy practising physicians, anaesthetists and surgeons, we inevitably have taken on the treatment of extremely sick patients whose time in hospital, despite very high levels of effort, ended with the death of the patient. Delivering bad news to relatives and loved ones is never easy but is very important and, in a way, helps to lighten the load on oneself. In the past, we might slink away, sleep uneasily for the next few nights and be somewhat withdrawn with our friends, partners and spouses. Alternatively, we may have debriefed with colleagues over a drink after the work day had ended – a situation now less common with the loosening of work ties associated with the reduced hours necessitated by the European Working Time Directive. But, showing compassion towards oneself is crucial if we are to continue showing compassion towards patients and their families. By taking time to debrief as a team and discuss what the experience of caring for a critically-ill patient was like, we can guard against the long-term effects of the stress of such challenging situations.2 Schwartz Rounds are one-hour meetings held in the middle of the day, preceded by a buffet lunch, a principle laid down by Ken Schwartz himself. A story is told by three or four people, of whom only one is a doctor. Each person speaks for three to four minutes about the care of a particular patient. There is no formal presentation. The rest of the room are invited to join the discussion by a facilitator, who is a senior nurse, and the lead clinician, a senior doctor. The presentation and discussion are confidential, and strenuous efforts are made to ensure that we preserve the anonymity of the patient. The Rounds stop promptly after 60 minutes. We have noticed that many of the audience linger afterwards to continue the discussions in smaller groups. We take this as one indicator that these Rounds are helpful. Preliminary analysis of the evaluation forms also suggests that there is considerable enthusiasm for these sessions. A few hours of preparation are required in the weeks leading up to the round and we have found that a ‘dress rehearsal’ on the morning of the Round is very helpful. It helps to highlight the key issues and provides leads to the subsequent discussion. We are about to embark on a prospective study to assess the impact of these Rounds not only on the panel members but on the audience, the hospital at large, and the patients. Meetings of this type are an effective way of providing the care team with an outlet to share their feelings with each other. This can help staff to understand that they are supported, their feelings are mirrored by others and that they are not isolated. It helps them to continue providing quality care even in highly emotional cases. Moreover, several participants have remarked that the process of preparation for these sessions has helped them to achieve closure on a troubling experience that had been niggling in their consciousness for many months. Six months into our Schwartz Rounds we are learning fast and have been helped enormously by the skill of a professional psychologist who acts both as our coach and quality controller. In any meeting of medical people the overwhelming desire is to try to solve the problem and focus entirely on the patient. These Rounds are different. We seek to bring problems of care into the fresh air, a process which requires a great deal of courage on the part of the participants. This process is not sterile but leads those in a position of power in the hospital to re-think the way we organize ourselves and seek to find better solutions. The true heroes of our hospitals are not the nurses or the doctors but the patients. Most patients are just ordinary people thrust into extraordinary circumstances and part of what enables them to be courageous is the compassion of those caring for them. It behoves us then to care for ourselves so that we can better care for our patients.