Compassionomics Read online

  The hidden curriculum is what medical students learn from resident physicians and attending physicians during all of the hours they spend together during clinical rotations in medical school that is not part of the actual “core” curriculum. It’s considered to be a side effect of a formal education…lessons learned—perhaps unintended—through the transmission of norms, values, and beliefs conveyed in the social interactions of the people in the educational environment.

  For instance, on a medical student’s obstetrics and gynecology (ob-gyn) rotation, the core curriculum may consist of learning about various types of surgeries that gynecologists perform: the indications for those surgeries, the anatomy involved in the surgery, and the steps that will take place in the operating room. It may include the complications that could arise and how to assess the patient both pre-operatively and post-operatively.

  Imagine for a moment: A medical student is called to the emergency department to see a patient with suspected ectopic pregnancy (sometimes called a “tubal” pregnancy – where a pregnancy grows outside the main cavity of the uterus). Within the core curriculum, the student might be expected to know the indications for taking the patient to the operating room for surgery.

  However, when the medical student is with the ob-gyn resident physician that gets the page from the emergency department about that patient, he will also learn a whole host of other things, such as how the resident speaks to the emergency department physician that calls for assistance.

  Is she annoyed by the call? Is she respectful? Does she answer the page right away or ignore the page and say, “If the emergency department really wants me, they will page me again”? Does she always treat the patient with courtesy and respect and listen intently? Does she really do all the things that are taught in the classroom?

  This is where the hidden curriculum comes in. While medicine abandoned a pure apprenticeship model years ago, learning the hidden curriculum—essentially learning by example—is still very much a part of how physicians are trained (or indoctrinated). The problem is that if mentors role model a lack of compassion in their day-to-day work with patients, new physicians will learn to do the same. That’s how they find out “how things work around here,” for better or worse.

  If mentors role model a lack of compassion in their day-to-day work with patients, new physicians will learn to do the same.

  There may be no better illustration of the hidden curriculum than in the pages of the infamous book, House of God, a best-selling satire with a cult following of medical students and physicians since it was first published in 1978.59 It has been described by many as “hilarious,” “troubling,” and a “scandalous” insider look into the hidden curriculum of medical school. In House of God, characters learn all the unwritten rules of how to practice medicine from a supervising senior resident they call “the Fat Man.”

  He teaches them all about GOMERS. That’s an acronym for “Get Out of My Emergency Room.” This awful term was used to describe older patients suffering from dementia who are not communicative and are repeatedly admitted to the hospital. The Fat Man teaches these trainees how to “turf” GOMERS: that is, how to find a way to transfer the care of these patients to other physicians so they can wash their hands of them.

  In short, it’s a heart-breaking look at the worst examples of depersonalization and passing these behaviors on to the next generation of doctors. It’s the polar opposite of what you will see in the pages to follow. The lessons from compassion science will teach us what it really takes to be successful in medicine.

  So remember: the hidden curriculum can have either a negative or positive effect on the training of compassion practices. It’s up to individual physicians, nurses, and other health care workers and administrators to decide what they want to role model. Their choices will have a lasting impact that echoes through trainees, mentees, and those that are less senior to them, all across the organization.

  Medical Progress?

  The introduction of the electronic medical record (EMR) into routine clinical practice represents an important advance for patient care quality and safety. However, it likely has not helped the human connection between health care providers and their patients.

  Since EMRs have been inserted into the patient-provider interaction, research shows that physicians in office practices spend at least as much time looking into their computer screens as they do looking patients in the eyes.60, 61 It’s been well studied. These days, kids draw pictures of physicians looking at a screen instead of their patient. And, when asked to describe the job of a physician, kids will say that he or she is someone who “types in a computer” rather than someone who wears a white coat and stethoscope.

  There is a thought-provoking JAMA article about a physician who was appalled by this very experience.62 This physician had just returned from two years serving as a medical officer aboard an aircraft carrier in the Persian Gulf making life-or-death decisions for a crew of 2,500 military personnel. He performed amputations and once had to divert an entire aircraft carrier to ensure a patient arrived safely at a tertiary hospital. As a result of such experiences, he developed a deep sense of purpose and strong commitment to service.

  Post-navy, during his residency training, he was recognized for being particularly gifted at connecting with his pediatric patients. So he was shocked when a seven-year-old girl drew this picture of him typing at the keyboard with his back to the family:

  Figure 1.1: The resident physician whose patient drew this picture captioned it like this: “The economic stimulus bill has directed $20 billion to health care information technology, largely funding electronic medical record incentives. I wonder how much this technology will really cost?”

  ©2011 Thomas G. Murphy, MD

  Do you see how this child has portrayed her doctor? His back is to the patient and family. Instead of growing up thinking of a pediatrician as a kindly person in a white coat who bends down to smile and look a small person in the eyes, the patient will think of him as a person who is disconnected from her experience…someone who is busy typing at a keyboard.

  The physician was simply stunned that his patient saw him in this way. As the article notes, this child’s picture aptly telegraphed the frustration felt by so many physicians who feel torn between the needs of today’s EMRs and their patients.

  Let’s take a moment to contrast this child’s picture from 2012 with another famous rendering from way back in 1891:

  Figure 1.2: “The Doctor” by Sir Luke Fildes, 1891

  Take a moment to carefully contemplate this famous Victorian painting, titled “The Doctor”, painted by Sir Luke Fildes. Do you see how this physician is fully engaged with his young patient? This child has one hundred percent of her physician’s attention. He is totally “locked in.” Nothing could distract him.

  Here’s how this painting came to be: Sir Henry Tate—sugar tycoon and founder of the famous Tate Gallery in London—commissioned a painting from Fildes, leaving the subject of the painting up to the painter. Fildes chose to paint this poignant moment that occurred during his own personal tragedy, before his young child died at home.

  But why? A comment from Fildes’ biographer (who was one of his other children) lends insight. He wrote, “The character and bearing of their doctor throughout the time of their anxiety made a deep impression on my parents. Dr. Murray became a symbol of professional devotion.”63

  So it’s a serious sign of the times when youngsters are sketching their doctors staring at a screen. The human connection in the patient-physician encounter is sacred; it facilitates healing. And yet, the EMR is not optional. Many physicians feel they must now give priority to data over attention to patients.

  Resident physicians on inpatient services spend only 12 percent of their time seeing their patients at the bedside in direct patient care.

  Athena Health ran an interesting television ad campaign recently on this theme with a video where a child was busy typing on a laptop as he “playe
d doctor” while his loving parents looked on. When they tried to express their approval, he gave them a stern look and held up a finger to chastise them for interrupting his work on the computer by speaking. (You can watch the video on YouTube by searching “When I Grow Up—Athena Health”.)

  The same problem exists in the hospital. A Johns Hopkins study found that resident physicians on inpatient services spend only 12 percent of their time seeing their patients at the bedside in direct patient care, compared to 40 percent of their time doing computer work away from the patients.64

  Again, it’s not just a U.S. problem. A recent Swiss study found the same thing: resident physicians spent about half of the workday away from patients (5.2 hours) working on a computer and only 1.7 hours with patients.65 It’s hard to connect with patients if one is working on a computer, let alone working in a different room.

  Providers may be doing work on behalf of patients while they are on the computer, but patients do not feel such attention. Nurses face the same struggle. It’s worrisome.

  It’s true that many physicians might opt to go back to a paper medical record if they could. However, there’s no question that the EMR is necessary to respond to the greater regulatory demands for documentation in health care today. EMRs have also improved patient safety and communication between physicians to review labs and procedures for patients and have delivered a host of additional benefits for health care systems.

  But all this comes at a price. Sometimes physicians can feel like glorified typists. They’re required to look at a screen instead of at the patient, and that changes the nature of their interaction with patients. Since the EMR won’t be going away anytime soon, there must be a way to do better. It has to be fixed.

  Why Do Providers Miss So Many Opportunities for Compassion?

  Is it really just because of the EMR? Taken together, there is abundant data in the scientific literature that health care providers miss most opportunities to respond to patients with compassion. But why?

  1. “I don’t see it.”

  Lack of insight is complicated. Does a provider just not notice these opportunities? Or does he willingly ignore them? It’s hard to know.

  It could be a lack of emotional intelligence, or not being comfortable addressing emotional needs. Maybe it’s being more self-focused instead of other-focused, as that University of Michigan study suggested.

  2. “I don’t have time.”

  The idea that providers don’t believe they have time for compassion dovetails with the results of the Princeton study of the seminarians. It’s a critical aspect to the compassion crisis. As a result, you’ll find that a full chapter is specifically dedicated to this crucial topic.

  3. “I don’t care.”

  The idea that providers don’t care about providing compassion to patients relates to health care provider burnout, or the emotional culture of the environment in which one practices. In the pages to follow, both of these important topics will be addressed.

  4. “I don’t know how.”

  This is the belief that compassion is not in one’s nature (e.g., “I am not a touchy-feely person”). The question is whether or not compassionate behaviors can, in fact, be learned through training (i.e., nature versus nurture). This will also be addressed in a later chapter.

  5. “I don’t believe it really matters.”

  And last is the question of whether or not providers believe compassion makes a difference. Debunking the myth that compassion is merely a “nice to have,” rather than essential for good outcomes, is one of the foremost aims in writing this book. It is a theme that will be running through all of the pages that follow.

  Change Is Slow in Health Care

  The reality is that it takes time to change norms in medicine. In the chapters to follow, you will see the data that compassion matters—for patients, for patient care, and for those who care for patients. But compassionomics is a new field of study. The scientific evidence behind practicing compassionate care isn’t widely recognized or appreciated…yet. But this is the story behind so many advances in medicine. It just takes time.

  Consider Ignaz Semmelweis, for instance. He was a grumpy Hungarian physician who is today widely credited with discovering the value of hand washing and aseptic technique in health care. But this wasn’t always the case. He faced a lot of detractors in his day.

  In fact, physicians didn’t begin to understand the value of hand washing until 1847. Before that time, the maternal death rate of women who delivered babies in hospitals in Vienna was ten to twenty times higher than those who delivered at home with a midwife.

  Dr. Semmelweis, who was Hungarian and Jewish, applied to work as a surgeon in the prestigious Vienna General Hospital, but was denied due to his nationality and religion. As a result, he was relegated to obstetrics where he routinely heard from patients begging to be discharged because they believed doctors to be harbingers of death.

  He began to question why women who delivered babies in the hospital were so much more likely to die of postpartum infections (i.e., puerperal sepsis or “childbed fever”) compared to women who were attended by midwives and delivered at home. He noted that physicians began their hospital rounds each morning by conducting autopsies on women who had just died and then moved on to delivering live babies next.

  Semmelweis deduced that doctors were transferring some kind of “morbid poison” between the corpses and the laboring women. (Today, that poison is recognized as pathogenic bacteria.) He then ordered physicians working with him to wash their hands in a chlorinated lime solution until the “stench” of the corpses was gone.

  Sure enough, the mortality rate of his patients fell dramatically. However, many of his colleagues stubbornly resisted the idea that they could have caused their patients’ deaths. They pushed back in the fiercest way. Semmelweis was an ornery person to begin with, and he became increasingly angry in the face of so much resistance to hand washing as an effective practice. Eventually, he lost his position in Vienna, and he hightailed it back to Budapest.

  It wasn’t until 1861 when he finally got around to publishing an academic paper on the subject (a paper that also included savage attacks on his critics). And even then, his mental health rapidly deteriorated until he was finally committed to a psychiatric hospital where he soon died.

  Semmelweis’ timing was bad. The medical profession just wasn’t ready to accept such a radical idea back in 1847. It wasn’t until Louis Pasteur began to set forth the most important tenets of his germ theory of disease in the early 1860s that the idea began to have context and take hold. In fact, it was in 1867 that the Scottish surgeon Joseph Lister—who hadn’t ever heard of Semmelweis—set forth his own theory of aseptic technique in surgery.66

  Will compassionomics have a better start than Dr. Semmelweis did? The majority of patients already connect with most of the concepts, as do many health care providers.

  However, medicine is slow to change, and the lesson of Semmelweis is not one to forget. Hopefully these authors do not suffer the same fate as Semmelweis did, but shining a light on the compassion crisis in health care is important. Even if some people disagree.

  CHAPTER 2:

  Does Compassion Matter?

  “Without data, you’re just another person with an opinion.”

  —W. Edwards Deming

  Seeing all the data on the compassion crisis in health care begs an important next question: so what?

  Does compassion really matter?

  Most of us probably agree that health care providers ought to be compassionate—that treating patients with compassion is the right thing to do. It’s a responsibility and a duty, a moral imperative.

  For the record, though, not everyone agrees that compassion is an “ought” to do, or that it is even a moral imperative in treating patients. For example, in response to the call to action for more compassion in the National Health Service in the United Kingdom (mentioned in Chapter 1), one high profile ethics professor went on the rec
ord as saying that compassion is not a necessary component of health care from any perspective.27, 67

  However, the overwhelming majority of health care providers and health care leaders in the U.S.—and around the world—have typically taken the position that a good bedside manner and treating patients with compassion is something that health care providers and health care institutions ought to do.

  But is compassion just an “ought,” or are there also evidence-based effects that would make compassion a vital and necessary part of the effectiveness of health care?

  Studies show that people believe compassion is vitally important for quality health care. Remember the Harvard study from Chapter 1 that was published in Health Affairs, where half of patients said both individual health care providers and the U.S. health system as a whole were not compassionate?1 In that same study, researchers also asked the 1,300 study subjects—including both patients and physicians—if they believed that compassion matters in health care.

  Three-quarters of both patients and physicians said “yes.” They also said it matters so much that it could actually mean the difference between life and death.

  However, those are just opinions. In medical science, and in health care, opinions are not enough. We need hard data to determine whether or not compassion matters in measurable, quantifiable ways…if it actually affects the health and well-being of patients.

  So the question becomes: can the effects of compassion actually be measured?