I recently took care of two young women with serious orthopaedic issues requiring multiple surgeries. Both patients had previously received peripheral nerve blocks as part of a multimodal approach to pain management. In most pediatric anesthetic practices, nerve blocks are done under general anesthesia because there is thought to be more risk of neural injury posed by an awake child moving during an uncomfortable procedure than there is benefit to be had from feedback during the block. In adults, however, the accepted risk-benefit relationship is reversed: if a paresthesia is elicited, most practitioners hope feedback will modify the procedural technique to decrease rates of neural injury. In reality, nerve injuries are rare and likely multifactorial so there is little data to support or refute either perspective.

Because these two young women were on the precipice of legal adulthood and cared for in a system that rarely sees pediatric patients, they had their initial nerve blocks mildly sedated. When pressed, each hesitated before acknowledging unpleasant memories of those experiences (despite midazolam), and increased perioperative anxiety given their planned repetition. High-level athletes, accustomed to discomfort as the price of performance, both were quietly stoic despite bloodshot eyes full of unshed tears.

I am the mother of a child who has developed a phobia of needles from encounters with the medical system. The autonomic and emotional dysregulation that occurs for my daughter when the topic is discussed reverberates through our family. It has resulted in our receiving, on a familial level, less-than-ideal care; the intensity of her fear even caused us to defer vaccinating all of our children against COVID-19. Because of my experiences with my own child, I routinely consider how to avoid negatively sensitizing pediatric patients for future health care encounters, even if that delays throughput. I discuss this openly with their parents, so that my rationale is clear and their expectations are primed. For both of these young women, I discussed the benefits and risks of doing their blocks under general anesthesia. In conference with their parents, both elected to be blocked asleep.

What struck me, twice, was how brave each young woman tried to be, and how grateful they were for an alternative to feigned fortitude: the opportunity for vulnerability, which in turn invited more compassionate care. It made me reflect on not just patient compliance, but the social compliance expected from young women, and the intersection of the two in the perioperative setting. I was grateful to have been able to offer something different, to validate them emotionally in the moment, but also to bolster their agency and self-advocacy for future medical encounters and beyond. Given pervasive bias and institutional sexism in medicine and our culture — from research neglect, to improper medication dosages, to political restrictions on bodily autonomy, to symptom dismissal and gaslighting — they will need all the support they can get, as early and as often as possible.

The idea that in caring compassionately for my patients, the positive impact that I can have may reverberate beyond the clinical space into both of our lives is anathema to the efficiency and production-oriented values of our modern health care system. After all, economics is, at its essence, a way of valuing things, and our health care marketplace overvalues doing and undervalues caring. And yet, research suggests that patients who are treated with more compassion by their anesthesiologists require less sedation medication preoperatively and less pain medication post-operatively, and that their wounds even heal faster with more structural integrity.

Claims like this, even with the backing of scientific evidence, are often met with incredulity as the ingrained response of a generation of doctors who have been inculcated as pure scientific rationalists. But that belies the origins of our profession, as healers, well-versed in the multidimensional nature of both sickness and health: physical, psychological, spiritual, and social. Though the scientific method has contributed massively to the efficacy of our interventions since the turn of the century, we are losing ground in the applicability of that expertise by virtue of distrust, skepticism, and fear. These are best understood as expressions of dissatisfaction with what has been lost in that transition: the primacy and power of human connection as the relational context in which healing takes place.

I thought about closing this essay with something like 5 Things You Can Do To Be a More Compassionate Physician. AI would probably create a better list than mine, which proves my point: compassion as a foundation for authentic connection cannot be generated by a list of performed behaviors. It can be learned, practiced, and improved in terms of fluidity and grace. But it arises naturally, despite awkwardness or uncertainty, from the desire to connect with others as an act of service. Seen this way, patients are people for whom the pejoratives “noncompliant” or “customer” no longer fit. Instead, they are companions on the bittersweet journey of ever-diminishing health (also known as aging). Physicians are authorities not just in the application of medical science to alter the natural history of disease, but in the compassionate care of the ill and dying. This is the expertise lost when we are aggregated into groups of “providers” in a system for which compassion holds neither literal nor figurative value.

So how do we get it back, the connection, the trust, a more effective therapeutic relationship? One answer is with cultivated connection, which starts with small things: eye contact, asking questions, listening for and caring about the answers. But it also arises naturally from the biggest things: self-knowledge and intentionality. Good news: We all have a career’s worth of moments to implement compassionate practices over myriad patient encounters. It may be more challenging to measure progress without the reams of data we expect as metrics of professional feedback. Instead, we will have to relearn how to follow our instincts to develop intimacy that merits the trusting vulnerability we need to not only not do harm but to do the most good.

Shannon Meron is a private practice anesthesiologist in Vail, CO.

Illustration by April Brust