Compassionomics Read online

  The Hypothesis: Compassion Matters

  In the same way that a quantitative, evidence-based approach was needed to determine that there is a compassion crisis in health care, a scientifically rigorous approach to examining the impact of compassion in health care must also be employed—measuring both the effects of its presence and the results of its absence.

  The goal was to determine whether or not it matters based on the evidence. Not just based on survey results that capture patients’ perceptions about their care, but also data from rigorous scientific studies showing the effects.

  To determine if compassion really matters or not, the question must be approached like an experienced researcher would approach it. At the beginning of answering any research question, the most important first step is always to establish the hypothesis.

  A hypothesis is a supposition or proposed explanation of the nature of things that is made on the basis of limited evidence as a starting point for further investigation. Then, the aim of the further investigation is to test the hypothesis in order to determine if it is true. It is important that the researcher is prepared to accept the path where the data leads, whether it supports or rejects the hypothesis. Researchers are not advocates for their hypothesis in the way lawyers are advocates for their clients.

  Researchers must remain free of bias as they test a hypothesis because the goal of research is never to prove a point. Rather, it is to test a hypothesis to find an answer. So it’s vital to be unbiased at the inception of scientific investigation.

  This kind of unbiased approach is necessary for the scientific method and to ensure that researchers won’t be led astray to false conclusions by any preconceived notions or biases, either conscious or subconscious. There is as much value in rejecting a hypothesis as confirming; either way, the body of scientific evidence grows.

  In these pages is the story of testing one overarching hypothesis: Compassion matters. Specifically, the hypothesis is that providing health care in a compassionate manner is more effective than providing health care without compassion by virtue of the fact that human connection can confer distinct and measurable benefits.

  Just to be super clear about bias: When we set out to determine whether compassion matters we were more than willing to conclude that it does not. As was explained in the preface that was exactly what we expected to find.

  Really, there are three interrelated hypotheses here: that compassion matters (1) for patients (through better patient outcomes); (2) for patient care (through higher quality, lower costs, and better financial sustainability); and (3) for those who care for patients (by promoting the resilience of health care providers and staff as well as lowering burnout).

  So these pages share the scientific evidence for compassion and its effects on health, health care, and health care providers. The clinical research data come from the real-world practice of medicine—quantitative and qualitative research that spans the spectrum from the primary care clinic all the way to the ICU and even extending to the hospital and organizational level.

  The Science versus the Art of Medicine

  Early on in medical school, physicians-in-training are taught about the science and the art of medicine. Nurses are trained in a similar fashion. The science of medicine is how to treat patients; the art of medicine is how to take care of them.

  The science of medicine is the collection of facts that comprise the knowledge base for how to make diagnoses and formulate treatment plans. But the art of medicine is different. The art of medicine is about building rapport and a caring connection with patients; some refer to this as “bedside manner.” It is undeniable that compassion for patients is an integral component of the art of medicine.

  However, in thinking that compassion is limited only to the art of medicine, one might be tempted to consider it distinct from providing medical care. That’s like thinking about compassion in the same way you think about dessert after the main entrée…a delicious “extra” to indulge in, but only after a great meal if you’re not already full.

  Following that kind of thinking, a physician’s most important job is to save someone’s life clinically, but, if there’s time, being compassionate to a patient is also nice. It’s just optional, a “nice to have.” (As emergency department nurses sometimes like to say, “I’m here to save your ass. Not kiss it!”)

  Where does such thinking come from? It comes from conventional medical training, where the science and the art of medicine are both considered vitally important, but very different. They are purported as separate and distinct from each other—mutually exclusive. Apples and oranges.

  Figure 2.1: The historical view: the science and the art of medicine are distinct.

  But what if the evidence shows there is actually overlap between the science and art of medicine? That is the hypothesis that is being tested here. Perhaps there is science in the art of medicine—a convergence.

  Figure 2.2: The compassionomics hypothesis: there is science in the art of medicine.

  Obviously, there are elements of the science of medicine that are distinctly science and elements of the art that are distinctly art. But the hypothesis is that there are situations and conditions in health care in which the art of medicine has not only meaningful, but also measurable, effects that belong in the domain of science. If that is the case, then compassion for patients belongs in the domain of evidence-based medicine.

  If compassion for patients is found to be a highly effective therapy that changes outcomes—one that is so much more cost-effective than many other therapies utilized instead—it would become part of every caregiver’s toolbox. You would use it at every opportunity you have, rather than considering it as optional.

  Such a therapy could radically improve patient lives, lengthen fulfilling careers for health care providers, and possibly help reverse the U.S. health care system cost crisis. But only if that is what the evidence shows. Just as researchers must be unbiased when testing a hypothesis, so should readers of this book be open to the possibility that compassion does not matter in measurable ways. Proof should be demanded.

  But similarly, many readers have been trained in the conventional thinking that the science and the art of medicine are distinct and mutually exclusive. That can also be a bias that, either consciously or subconsciously—no matter how much evidence is presented—could make a reader unable to consider the possibility that the hypotheses presented here are true.

  Bias is notoriously difficult to overcome. It’s okay to be skeptical, but don’t let it cloud your consideration. Dare to open your mind. Open your mind to the possibility that compassion is actually more powerful than you ever dreamed. Demand proof, of course. But do it with an unbiased mindset that is open to possibility. After all, that is what the scientific method is all about.

  The Journey through the Data

  Before showing you the evidence, let’s look first at the methodology used to test this hypothesis to learn how the scientific evidence was compiled from the biomedical literature and understand how the data were synthesized. Then, after evaluating all of the scientific evidence, you can decide for yourself whether or not compassion really matters. You be the judge.

  The data presented in these pages are not the product of “cherry picking” certain studies from the scientific literature that show compassion matters. Rather, the data were compiled using a bona fide research methodology called “systematic review.”

  The genesis of this book is not a look at what some or a few of the studies on compassion in health care showed. Rather, it’s systematically what the compilation of the studies on compassion revealed after they all were chased down and reviewed.

  A systematic review is a type of scientific literature review that uses a systematic methodology to collect, critically appraise, and synthesize all of the data available in the world’s literature on a specific question. It is the process to cast the widest net to capture all the information on a single topic. Systematic review is consid
ered to be one of the most important tools for establishing the state-of-the-art in medical science.

  The purpose of a systematic review is to provide a complete, exhaustive summary of current literature relevant to a research question. The purpose in this case: does compassion really matter?

  This general approach is outlined in the Cochrane Handbook for Systematic Reviews of Interventions, which is considered the “bible” of systematic review containing all the rules for examining a health care question.68 Essentially, every relevant article and available piece of data was reviewed to examine the hypothesis that compassion matters.

  However, examining a special topic like compassion in medicine requires a special approach. Conventional systematic review methodology is not sufficient. The conventional method for systematic review is to use a protocol-driven search strategy of an electronic database of evidence (e.g., the search engine PubMed from the National Library of Medicine).

  But compassion is a topic that falls into a special category of systematic review called “complex evidence.”69 Complex evidence is that which addresses broad questions—like health policy, for example—and synthesizes both qualitative and quantitative evidence from multiple and disparate types of sources.

  Research shows that conventional protocol-driven database searches will miss more than half of the relevant data when examining topics of complex evidence.69 As a result, conventional search methodology is inadequate.

  This systematic review is the first time all of the data on compassion’s impact on health and health care has appeared together in one place.

  Here’s an example: If the search term “pneumonia” was typed into PubMed, all of the articles that contain information about infections in the lungs would be mapped to that term. A researcher could feel confident, as could the rest of the scientific community, that no relevant research would be missed.

  However, the data for compassion science has not been mapped to a single search term or curated in the same fashion. You can’t just enter the search term “compassion” and get all of the relevant studies. As a result, this systematic review is the first time all of the data on compassion’s impact on health and health care has appeared together in one place.

  Think of the early days of the internet and search engines. Until technology improved and a company like Google came along to map terms more extensively, searches were much less accurate. So if you wanted to search for everyone in the country named Charlie Brown, you would be relying on a search engine to know that people may go by Charlie, even if their name is Charles or Chuck or Charlene or Charlotte.

  Or maybe they are just listed as “C.” Or perhaps Charlie is their middle name. Fortunately, search engines are now sophisticated enough to figure this out for us. But what if they couldn’t? In that case, you’d be forced to know all of the forms of every word, in every instance, to make sure you didn’t miss someone.

  Since compassion science has not been mapped (yet) in publication databases, one cannot simply type the search term “compassion” into PubMed and get all the relevant studies. It’s not that simple, unfortunately.

  Compassion science is a field so new that there is no single adequate search term. As a result, relevant research studies may be mapped to very different search terms in databases—terms like “doctor-patient relationship” or “rapport,” perhaps “humanism” or even “bedside manner.”

  Figure 2.3: Compassionomics is a field so new that there is no single search term.

  Studies that are mapped to these search terms in electronic databases and search engines may contain data that are very relevant to an examination of the effects of compassion in health care. The conventional systematic review methodology would likely miss much of the pertinent data. Therefore, for the systematic review of the evidence on compassion, a much more laborious methodology was needed.

  The Sherlock Holmes Approach to Getting Answers

  In accordance with the recommended methodology for systematic reviews of complex evidence,69 this systematic review of compassion took a much more hands on (and painstaking!) approach. It’s called a “references of references” methodology.

  So, instead of simply typing terms into a search engine, this review started with a small collection of the studies considered to be quintessential papers on the effects of compassion in medicine and then worked backward. By going to the references section of each of these classic studies, every paper listed in the references section was then, itself, reviewed for pertinent data.

  Then the reference section of each of those papers was reviewed. And each of those papers were pulled. And their references were reviewed. And so on, and so on…until there was no longer any relevant data to be found. You can think of this methodology as a “family tree” of sorts, ever growing and branching out…until every last reference was exhausted.

  More than 1,000 scientific abstracts were examined and reviewed as well as more than 250 research papers.

  In total, more than 1,000 scientific abstracts were examined and reviewed—by hand—as well as more than 250 research papers. What was particularly valuable about this methodology was that it captured key scientific studies that had been flying under the radar for years, even decades. To capture all of the relevant studies is vital because it allows a thorough review of the data in aggregate over a long time span for greater validity.

  Surprisingly, some of these “under the radar” studies were even conducted by some of the most respected institutions—like Harvard Medical School—and published in some of the best journals—like The New England Journal of Medicine. How is it that such high-profile publications can go missing? These studies likely garnered a lot of attention at the time of publication, but over the years they were not connected to other studies in a way that produced a pattern. They didn’t influence medical practice in the same way that change was occurring in other fields of medicine, where studies and scientific findings were continuously building upon each other over time.

  At the time of publication, people likely found these papers on the power of compassion incredibly interesting and perhaps also very impactful. They made ripples in the water, and some studies probably made a substantial splash.

  But they did not connect with other studies to make a wave that could transform health care. But with the methodology in this systematic review—that finally connects all of the key studies together—the ripples and splashes form an unmistakable tidal wave of data that will show you the true power of compassion and lead you to only one conclusion. (Spoiler alert: compassion matters.)

  Given that some of these vital studies had been published up to fifty years earlier, this systematic review required cracking open the spines of journals physically located in the bowels of a library—dusty journals which, in some cases, probably hadn’t been peered into for decades. That is why this systematic review on compassion science literally took two years to complete.

  So rather than typing terms into a search engine and getting an instantaneous output with all the studies, this two-year systematic review was much more like using a library card catalog and the Dewey Decimal System to find books on a remote shelf in a library sometime before the internet. (Note: If you’re a millennial or younger, you might need to take a moment to Google “card catalogs and the Dewey Decimal System” to understand what was involved in research pre-internet. It was an incredibly time-consuming endeavor.)

  Essentially, this systematic review was a methodical “Sherlock Holmes” type of investigation searching for clues and evidence on the power of compassion. The “references of references” methodology was slow going, no doubt, but that is what a systematic review of complex evidence requires.69

  Earlier, a distinction was drawn between the meaning of empathy (the feeling and understanding components) and compassion (the action component). It’s important to note here that, for the purposes of synthesizing and presenting the available research in an understandable way, the word “compassion” may be us
ed as we discuss some studies, even though the term “empathy” may be used in the title or body of the paper. The body of research shows that authors often use these two terms interchangeably.

  The important thing is that studies were included in this systematic review if they met the threshold of this working definition of compassion—an emotional response to another’s pain or suffering involving an authentic desire to help—whether or not the study authors called it compassion.7 If what the study was examining met this definition, then in this systematic review (and throughout the rest of this book) it will be referred to as compassion.

  Think of it this way: Since empathy is the feeling or understanding of another’s pain or suffering—and compassion is the action that flows from empathy—then anytime a study examines health care provider behavior toward a patient, the study must involve compassion.

  Empathy is like a one-way street running toward the health care provider: detecting, processing, understanding, and even feeling the incoming emotional cues from the patient. Compassion, on the other hand, is a street that runs in the other direction, a responsive action toward the one who is suffering. Empathy can happen through a one-way mirror. Compassion cannot.

  So if a study involves behaviors toward a patient, it has to be (by definition) a study of compassion, even if the authors of the study chose to use the term “empathy” instead. Accordingly, throughout these pages, anytime a study involves behaviors toward a patient, we will (for our purposes) refer to it as compassion.