The themes which shed light on and build understanding of the novice doctors learning to be compassionate, when engaged in a complex community of practice, are listed in Table 1 and discussed below:

Table 1 - List of identified themes

Identified Themes Ill‑prepared and overwhelmed Pursuing Perfection and Fearing Failure See‑Sawing Self-efficacy Distancing emotion Transcending doctor identity – common humanity

Ill‑prepared and overwhelmed

I've started my internship in Emergency. The first two weeks were so overwhelming, it was like being a medical student with too much responsibility… I wanted to cry at some point during every one of these shifts and was adamant (sic) it was unfair to throw us in the deep end like this…

(Grace)

Despite being exposed to clinical practice during rotations as medical students, a key theme highly influential in shaping the learning trajectory and practice of each of the participating interns, was the way in which they struggled with the entry to their internship. While being ill‑prepared is a familiar trope in the literature (Ackerman et al., 2009), (Brady, Corbie-Smith and Branch, 2002), (Kilminster et al., 2011), central to this interpretation of their transition in the context of compassionate care is their emotional response to their new role. The enormity of the responsibility required of the interns initially took them by surprise, resulting in emotional turmoil and vulnerabilty. They were scared, shocked and overwhelmed by their experiences during this daunting transitional period.

Pursuing Perfection and Fearing Failure

How can you transcend to be perfect and compassionate and empathetic clinician when you don’t know where you stand?

(Trevor)

A significant theme interpreted through the interns’ narrative is the idealised notion of perfection. Wanting to be a ‘good’ doctor quickly morphed into aspiring to perfection. Perfection, in this context, is a complex construct resulting in narrow, risk aversive behaviours as they attempt to grasp for increased control over their work environment, all ostensibly linked to the fear of failure. Failure to fulfil the requirements of the good doctor identity enmeshed in their clinical role: an identity framed by the interns’ unmet expectations and aspirations based on an idealised notion of perfection – the perfect doctor, with perfect knowledge administering care to the perfect patient – compounded by the overwhelming sense of uncertainty they confronted in undertaking the responsibilities of their role in a messy and complex workplace.

See Sawing Self-efficacy

The interns’ self‑efficacy had a major influence on how they delivered care. Their own perceived success or failures derived primarily from biomedical competence, in addition to the consequences of observing their peers and colleagues as both positive and negative role models – contributed to how they learned to care. Feedback from peers, senior colleagues and patients was central to their ongoing confidence and competence creating a seesawing effect, where positive or negative feedback created an emotional rollercoaster heightening their vulnerability.

Within the interns’ narrative it is evident that their self‑efficacy, how they perceive they are performing in their prescribed role, (Bandura, 1994) is shaped both implicitly and explicitly.

Certain stressors tend to affect my mindset such as workload and support from the senior doctors. When the senior doctors are critical then it affects my confidence in being able to adequately care for patients, and this in turn makes me feel like a fraud in front of my patients and as if I do not have the right to be caring for them and showing compassion. The reverse of this is that when I feel like I am doing well at my job I find it very easy to have compassion.

(Nathan)

Their emotional response, both embodied, (expressed physically, for eg. wanting to vomit), and visceral, (expressed emotionally for eg. in wanting to cry), sat uncomfortably with the professional identity they wished to create for themselves as a doctor in competently meeting their patients’ needs and conforming to cultural norms of their profession.

Distancing Emotion

Reflecting the unwritten rules of their community of practice, the hidden curriculum, ‑ where emotion is either noticeably absent (McNaughton, 2013) or continues to be reframed as detached concern (Coulehan and Williams, 2001), the interns preferred to ‘act on the side of coldness’ (Intern Nathan) rather than to be seen as too emotional.

Their journal entries are replete with their emotional responses in wanting to cry, and/or vomit, feeling sad, putting their emotions on hold (e.g. going home to cry), while simultaneously drawing boundaries around the emotional needs of their patients by not engaging too closely.

I hate it and I'm counting down the days. This is also mainly about working with families but it is within a geriatric population. They all remind me of my own grandparents and it pulls on my heart strings. I do a lot of ‘Not for resuscitation’ orders, death certificates and family meetings. I almost find it bizarre how removed I am from it, I don't know if it is a lack of interest in the area or just a protective mechanism.

(Grace)

This triggered a range of protective behaviours as they built a protective armoury, erecting barriers around emotion and patient engagement.

The Triage of Compassionate Care

Alongside the expectations the interns created for themselves as doctors, they simultaneously held an idealised notion of the ‘perfect patient’. This idealised notion of the perfect patient, portrayed the patient as someone likeable, treatable and grateful: a romanticised representation far removed from the reality of day to day practice.

Contrasting with this idealised notion of the perfect patient was the patient whose behaviours and attributes were perceived by the interns to manifest in a range of negative ways directly influencing how they provided care.

In her journal entries, Mary describes her ‘worst patient’ as follows:

Worst patient I’ve had is probably this drunk who threatened to rape the female staff and swore and threw punches and refused treatment….I handed him over to another intern, a male one because like hell I was going to stay around to be abused like that.

(Mary)

A constant thread recurring through the interns’ reflections is the belief that, if the patient’s behaviour is perceived to be inappropriate, presenting with what they perceive to be trivial problems, then they are less deserving of ‘extra’ care. Compassion appears to be an optional adjunct to their role with medical knowledge, clinical reasoning and procedural skills determining their core competencies as a ‘good’ doctor.

Transcending the Doctor Identity – Common Humanity

Most significantly, as the interns completed their full, year-long internship, a shift in their thinking, attitudes and behaviour became evident. There was evidence of resilience and empowerment which enabled them to reconnect with their original intent to be a compassionate practitioner.

Once they felt confident and competent and, as they incrementally became more comfortable with their role and identity as a doctor, they were afforded the time to be more caring for their patients. They referred to ‘the little things’ – finding a blanket, making sure the patient is not hungry or thirsty – little things – which you do not need to be a doctor to do. These ‘little things’ which they consider ‘not doing anything’ – the very ‘things’ as illustrated by Grace in her journal, perceived as so meaningful to the patient as an expression of care:

There's heaps of anti‑emetics [for vomiting] and analgesics to offer patients and besides that a bottle of water or an extra warm blanket never goes astray.

This term has probably taught me a lot about doing the things that make people feel cared for even if it’s not the things that make you feel that you are caring for them. To me, caring for someone is giving them a diagnosis, a prognosis or a solution. For them it seems that it’s more about the little things. Whether that’s because patients associate caring about the small things with caring about the big things or because patients in pain care more about their sore foot than their heart failure that is causing it I don't know. Either way, I'll be offering more bottles of water from now on’.

(Grace)

For Mary, her final journal entry illustrates how the everyday demands of the role continued to intrude on her desire to be compassionate. As she finished the year she reflected on the relevance and meaning of caring in a compassionate way:

Compassion tends to be the first emotion ditched when I’m busy. Intellectually, I know I should care about what the patients and their families are going through but it’s just easier not to because there’s no time. Got to get that cannula in. Get those bloods sent off. Get the referral done. Get imaging forms in. I was filling out the care of the dying pathway form and I realised I hadn’t even SPOKEN to the patient or his family. But I just didn’t care. Until now …

(Mary)

In his final journal entry for the year, Nathan captures the essence of many of the inter‑related themes referred to across the interns’ narrative and subsequent analysis. He writes how, initially focused on developing his identity as a doctor, he crafted a professional persona which created boundaries and a power differential within the ‘doctor patient relationship’, emphasising difference rather than sameness – a relationship he now challenges:

After a year of working I feel I have reached a conclusion regarding compassion. The term ‘doctor‑patient relationship’ is a term which reminds us to consider themes like duty, confidentiality, boundaries, power differential and illness. But I feel this term detracts from the real relationship which is a human‑human interaction.

(Nathan)