Compassionomics Read online

  So it’s not just a U.S. phenomenon. It’s everywhere. When depersonalization is combined with emotional exhaustion, it culminates in compassion fatigue—literally running out of compassion for patients.

  Burnout Starts Early

  Trainees are also at risk. In one University of Pennsylvania study that followed 47 physicians in training over their intern year (i.e., the first year out of medical school), there was a sharp increase in depression; one-third of students experienced it.32

  Depersonalization rose over time in the students studied, as did emotional exhaustion. As you might expect in light of these developments, researchers found that these students also experienced a reduction in empathy for patients over their intern year.

  This study was building upon research published in the Journal of the American Medical Association (JAMA) that showed empathic concern decreased over the first year out of medical school for junior doctors.33 And without empathic concern (the feeling component), there can be no treatment with compassion (the action component).

  Unfortunately, burnout is a hot topic in medicine today because so many physicians and nurses, in every stage of their career, are struggling with burnout and its consequences. Look for more about the link between compassion and burnout in chapters to follow, but for now, just recognize that the association between the two is well documented in the medical literature.

  The thing is, taking care of patients and working in health care is not just a job; it’s a calling. Health care providers share in the most intimate aspects of people’s lives, often in their darkest and most difficult moments.

  The compassion crisis could turn the profession of health care providers from a calling into a job.

  The relationship that caregivers have with their patients—whether a physician, nurse, or any type of health care provider—is supposed to be grounded in both the art and the science of medicine. But the data shows quite clearly that some of the art is, in fact, disappearing.

  In other words, the compassion crisis could turn the profession of health care providers from a calling into a job. There are 18 million health care workers in the U.S. alone, so this is a huge problem. If these clinical interactions are devoid of compassion, the relationship between caregiver and patient could become essentially no different than any other customer service relationship. That just can’t be allowed to happen.

  Why not? Health care needs to be a calling. Walking with people through the worst, most intimate moments of their lives is a sacred thing. That requires a level of personal interest and investment by health care workers. When patients’ health and well-being are at stake, time, emotion, empathy, and compassion should be non-negotiable.

  But multiple studies indicate that many health care providers aren’t even hearing their patients’ worries. So it’s no wonder that many patients experience a lack of compassion. In one study published in Annals of Internal Medicine, researchers recorded the audio from primary care office visits and found that 77 percent of the time, physicians interrupted patients before they completed their opening statement of concerns.34

  How long did they wait before interrupting the patient? Seventeen seconds.34 The study that produced this data was published in 1984. At that time, the medical community took notice of this finding. As a result, a large number of medical schools, training programs, and continuing medical education programs added communication skills and techniques to the curriculum to address this issue.

  Then a repeat study entitled “Soliciting the Patient’s Agenda: Have We Improved?” was published in JAMA 15 years later. The new time to first interruption? Twenty-three seconds. Better, but still short of the time that the researchers found that patients actually need to state their main concern.35

  How are we doing in the most recent look at this data? Worse. Much worse. A 2018 study from the Mayo Clinic now clocks the time to first interruption at 11 seconds!36 By the way, researchers have found patients only need, on average, 29 seconds to state their main concern.35

  Do Health Care Providers Believe It?

  Here’s the funny thing…in so many studies, patients agree there is a compassion crisis in health care today. After compilation of all the scientific studies, but prior to writing this book, we were interviewed by Philadelphia Inquirer’s Stacey Burling who wrote a front-page article that highlighted the evidence for a compassion crisis in health care.2

  There is abundant data that physicians routinely fail to demonstrate compassion.

  Within 24 hours, more than 30 markets picked up the story off the Associated Press wire. There was a widespread, intuitive, and immediate understanding of this problem based on the repeated personal experiences of people all across America—especially those who do not work in the health care industry.

  The idea of a compassion crisis really resonates with most people. But health care providers are less sure of this and often don’t believe there is really a problem. They seem to be in denial.

  However, there is abundant data that physicians routinely fail to demonstrate compassion. In one University of Chicago study supported by a federal research grant from the Agency for Healthcare Research and Quality (AHRQ), researchers analyzed hundreds of audiotapes of surgeons’ clinic visits with patients.37

  What they found was that these consultations had a narrow biomedical focus. There was very little discussion of the emotional and psychological aspects of the problems those patients faced with their health condition. Furthermore, when rigorously measured, the researchers found that only 0.5 percent of statements by surgeons expressed any compassion. Less than one percent!

  “But the Docs I know Are Compassionate”

  It’s interesting how often people have critical opinions of others but are much less likely to have the same critical opinion of themselves (or others close to them), despite similar behaviors. Perhaps that’s just human nature?

  Here’s one example: The polling company Gallup has found that while people may have a very low overall approval rating of Congress, they often have a much higher approval of their own representative in Congress. This number goes up even higher if they know the name of their representative.38

  In the same way, health care providers may believe and acknowledge that other providers are not compassionate, but still believe themselves to be so. They may also believe that they are more compassionate than their patients actually find them to be. It is what psychology researchers would call a cognitive bias. They seem to have a “blind spot” on their ability to relate to and connect with patients. There’s research to back this up.39, 40, 41, 42, 43

  In one study, researchers studied doctors’ emotional intelligence to understand the associations between emotional intelligence, patient trust, and the doctor-patient relationship. What they learned was that how the doctors self-rated on emotional intelligence didn’t correlate with how their patients viewed them.43

  Research shows physicians routinely miss emotional clues from patients and actually miss 60 to 90 percent of opportunities to respond to patients with compassion.

  In fact, it was nurses in the study who had a more realistic view of the doctors’ emotional intelligence. As independent (i.e., third party) observers, the nurses’ scoring of the physicians’ emotional intelligence mirrored what patients said they experienced. In short, doctors’ insight on their own ability to connect with patients just wasn’t very accurate. But the nurses could see it. This may not come as a surprise to any nurse reading this book.

  Research shows that physicians routinely miss emotional clues from patients and actually miss sixty to ninety percent of opportunities to respond to patients with compassion. This is even true in cancer care, despite the fact that cancer patients are likely to be in need of compassion.

  The evidence in cancer care comes from a number of rigorous, federally funded studies from reputable, internationally recognized research institutions like Duke University and University of California San Diego and were supported by grants from the Na
tional Cancer Institute and the AHRQ.44, 45, 46, 47

  And those findings about missed opportunities for compassion in cancer care? They’re corroborated by a host of other studies in other types of medical practices. A National Institutes of Health (NIH)-funded study from University of California San Francisco found that in communicating with acutely ill patients admitted to the hospital, hospitalists (specialists in hospital medicine) miss 68 percent of opportunities to respond with compassion.48

  Would it surprise you to know that hospitalists miss so many clues and opportunities? Perhaps not. Hospitalists are a newer medical specialty. As individuals who coordinate the hospital care of many inpatients, maybe it’s harder for them to develop much of a relationship or rapport with their patients in the way you would anticipate from doctors who come to know their patients over many years.

  But guess what? A University of Chicago study—that was published in JAMA and funded by AHRQ—found that in primary care clinic visits, primary care physicians missed 79 percent of emotional clues from patients and opportunities to respond with compassion.49 So there goes that theory…

  So Many Missed Opportunities

  When a patient says, “I’m having a tough time,” the hope is it might prompt some type of compassionate response from health care providers, either by using a “continuer” question or statement (instead of a “terminator” statement that stops the dialogue in its tracks) or just by offering emotional support.

  But research shows that, more often than not, physicians just blow right past those opportunities for compassion. They don’t acknowledge what was said or engage, listen, or connect in a meaningful way. Instead, they move on to a next area of inquiry. The preponderance of data in the medical literature shows this.

  There are countless stories of patients who see multiple physicians before they finally sit with a physician that listens to every aspect of their history and then catches the smallest detail that can finally lead to the right diagnosis. Oftentimes, these second and third opinions finally help a patient receive the care they need.

  But the inability to understand what a patient is really trying to say—or perhaps is not saying—can be a matter of life or death. It is now known that most people who attempt suicide have made some type of health care visit in the weeks or months before the suicide attempt—38 percent of them within the last week and 95 percent within the last year.50

  The stakes are so high and the risks of missing warning signs so great, that some institutions have adopted screening tools, like the Columbia Suicide Severity Rating Scale, to assess all patients with depression in certain settings (e.g., the emergency department or primary care).51 One of the main reasons why scales like this exist is that health care providers are often not detecting the emotional and other cues that could indicate someone is about to take their own life.

  Part of the problem is experiential in nature; health care providers in these settings typically do not have focused expertise in evaluating suicide risk. But the other part is that the health care providers may not be emotionally attuned or attentive to what the patient is saying (or not saying). But what if they were?

  In his book, Why People Die by Suicide, renowned psychologist and suicide expert Thomas Joiner from Florida State University quotes from one man’s suicide note: “‘I’m going to walk to the bridge. If one person smiles at me on the way, I will not jump.’”52

  One smile is all it would have taken to change such a terrible outcome.

  None of the people this man passed on the way to the bridge had any idea what kind of pain this man was carrying around…carrying it all the way to ending his own life. From their vantage point, this man may have looked like anybody else.

  Yes, you never really know what kind of pain people are carrying around. What about the people that man passed on the way to the bridge? How do you think they might have responded if they knew that the man they barely noticed could have been saved by the compassionate act of a single smile?

  They would probably be devastated to learn that they missed an opportunity to save a life. That is just how health care providers in emergency medicine and primary care feel when they learn the shocking news that a patient who just left their emergency department or clinic took their own life. They second-guess everything they did (or did not do). They are devastated by the missed opportunity to potentially make a lifesaving difference.

  In fact, sometimes the end of that patient’s life literally ends a physician’s health care career. He or she never recovers. A missed opportunity for compassion can change the trajectory of ones’ life—for both the patient and the provider—forever.

  A missed opportunity for compassion can change the trajectory of one’s life forever.

  And it’s not just suicide where providers can save a life. Missed opportunities for compassionate care are also common for patients suffering during the most severe physical health crises. This is not opinion; these are the scientific data.

  Consider this shocking example from a rigorously conducted Johns Hopkins study: Trained observers set about measuring health care providers’ verbal and non-verbal communications in the intensive care unit (ICU). In fully 74 percent of the interactions in the ICU, researchers found that the health care providers showed no compassion for patients or families (i.e., zero compassionate behaviors).53

  Likewise, in another study from the University of Washington and supported by the NIH, researchers found that fully one-third of end-of-life discussions with families in the ICU had no statements of compassion by health care providers—zero—even though they also found that compassion leads to a better experience for families.54

  Isn’t that a little crazy? If there were ever a time that people need compassion, it would be at the end of life. It is important to recognize that, just as there is typically a bell curve in all aspects of human performance, there is also a bell curve in people’s compassion for others. This variation has been demonstrated in health care providers as assessed by patients.55

  This will be discussed in detail later, when considering methods to increase compassionate behaviors, but for now suffice it to say that variation in compassionate care between health care providers is a major source of the lack of compassion in health care. In addition to variation between providers is variation within individual providers—i.e., inconsistency in one’s compassionate care.

  There are bad days for every provider, of course. But some individuals manage to find compassion anyways. Even on bad days.

  Dr. Phil Koren, a cardiologist and head of the heart institute at Cooper University Health Care, for instance once explained that he recognizes patients must often wait weeks to see him. So even if he’s having a challenging day, he consciously works to set aside those feelings to muster all the compassion he can.

  He recognizes that he’s “on”—just like a performer on stage—when he sees a patient and that each patient deserves his compassion. Incidentally, he also finds that the extra investment of compassion and the patient interactions that flow from that actually fuel his passion for medicine and increase his fulfillment with his career. (This link between compassion and resilience will be reviewed in-depth in a later chapter).

  There is an expectation for emotional labor in all service industries. Health care is no exception.

  This isn’t to suggest that health care providers “fake it,” but rather that they recognize there is an expectation for some emotional labor in all service industries, and that health care is no exception.56

  Of course, there are exemplary health care providers who are truly experts at compassionate care and consistently show compassion for every single patient, every day. However, consistency is lacking with many providers, and the preponderance of evidence shows that what patients are experiencing is falling short.

  Could Lack of Compassion Be a Learned Behavior?

  As discussed earlier, physicians-in-training struggle with burnout just as their more seasoned peers do. This leads
to compassion fatigue. In fact, compassion tends to decline over time throughout medical school. The phenomenon has been well studied so there is a lot of supporting evidence.

  But there is also another dynamic at play here. In a systematic review of 18 studies of empathy in medical trainees, 17 of 18 studies identified that empathy declined during training.57 However, they also found that a major reason was the “hidden” curriculum.

  The core curriculum is, of course, the outline of the substantive knowledge to learn on a particular topic. The hidden curriculum is “that which the school teaches without intending or being aware that it is being taught.”58

  Let’s pause for a moment and identify the players in medical education. Medical students, who are also known as “student doctors” or “physicians-in-training,” are students enrolled post-college in a school of medicine. Resident physicians, who are sometimes known as “house staff” physicians, are recent graduates of medical school who are training in a particular field of medicine but have not yet begun to practice completely unsupervised. Finally, attending physicians have finished training in their particular field of medicine or surgery and are the supervisors and teachers of medical students and resident physicians in teaching hospitals and academic medical centers.