Compassionomics Read online

  An interesting side note: The data also show that there’s been a spike recently in the number of researchers studying compassion.70 This is in stark contrast to, say, the number of researchers currently studying the bubonic plague.

  No spike there. Why? There is no bubonic plague crisis any longer. It doesn’t matter anymore. However, interest in studying compassion for others seems to be at a fever pitch. There is a worldwide compassion crisis at the moment. Right now. And it matters.

  How Compassion Works

  Whenever researchers hypothesize that there is a link between two things—a factor under investigation and the outcome measure of interest—they always postulate a mechanism of action: By what mechanism did the factor affect the outcome? What mechanism causes the effect?

  For example, with medications for treating mental health conditions, the mechanism of action may be a drug binding to specific receptors in the brain or modulating the levels of neurotransmitters in the brain. For medications to treat high blood pressure, the mechanism may be a drug binding to receptors in blood vessels throughout the body.

  But in the case of compassion, how is it that compassion can have meaningful effects? What are the mechanisms of action? There has to be a mechanism of action in order for there to be a meaningful effect.

  During this systematic review of the scientific evidence, more than twenty distinct mechanisms of action for compassion on patients came to light by which compassion can have meaningful, beneficial effects on patient outcomes.14 These can be grouped into four main areas: physiological effects, psychological effects, enhanced patient self-care, and increased quality of care.

  What do those encompass exactly? Here are a few examples as a preview of the data to come: When providers have compassion for a patient, they are more likely to be meticulous about their care, have higher quality standards, and are therefore less likely to make a major medical error.

  But there are also physiological effects. For example, compassion can buffer stress-mediated disease. Compassion can also modulate a patient’s perception of pain.

  There are also endocrine effects, like improved blood sugar control in patients with diabetes and enhancement of immune system function. The psychological benefits of compassion can also be immense (which is probably not surprising). But you may be surprised to learn that compassion for patients can also motivate patients to better self-care, i.e., how patients take care of their own health. And that is critically important.

  For example, when providers care deeply about patients—and patients feel that—they are more likely to take their medicine. These mechanisms are the “how” when it comes to understanding the enormous power of compassion.

  A very important caveat to keep in mind as you consider this evidence: the main driver of clinical outcomes is clinical excellence. Period.

  Of course, compassion is not a panacea; it’s not a substitute for quality clinical care. If a surgeon botches the technical aspects of a surgery, or a physician makes an error by prescribing the wrong drug, there is no way that compassion can make up for that.

  But when compassion is used in conjunction with excellent clinical care, it can be incredibly powerful. Don’t think of clinical excellence and compassion as an “either/or” situation. It should be an “and,” as in “clinical excellence and compassion—when used together—deliver the best outcomes.”

  Also, it is important to consider the entire spectrum of outcomes. You will see some impressive data that demonstrate the power of compassion, including decreases in mortality. However, it is important from the outset to set expectations, with respect to the concept of “curing” disease.

  For example, in these pages, you will not see any evidence that compassion shrinks tumors in patients with cancer. However, you will see a body of very compelling evidence that compassion can have a major effect on how a cancer patient experiences their disease (e.g., the severity of their symptoms).

  Is that an important goal? Just go ask a cancer patient. Unfortunately, in some cancer patients with incurable disease, the patient’s experience is the only goal that can be impacted. Accordingly, achieving a “cure” is not the only important outcome measure in medicine.

  Now that you understand the methodology of this systematic review of the scientific literature, let’s look next at the actual data on the effects of compassion for patients. The main thing to remember is this: It’s important to stop thinking about compassion in a sentimental or emotional way. Rather, start thinking about compassion in a scientific way. It’s all about examining odds ratios, confidence intervals, and p-values in making the case for compassion.

  If you don’t know what these statistical terms are, don’t worry about it. Just realize that the scientific bar for evidence in the systematic review in the pages to follow is very high. It’s the same bar for the evidence used to prove the benefit of any medication you took this morning, or the surgical procedure that your family member underwent recently. If you are a health care provider, it’s the same bar used to establish the standards of medical care in your specialty.

  If, after seeing all the data in the pages to come, you still believe compassion is just a “nice to have,” then you’re likely not using evidence-based thinking. That’s like continuing to believe in leeches, bloodletting, and the ancient Greeks’ system of the “four humors,” where interactions of certain bodily fluids—blood, yellow bile, black bile, and phlegm—were believed to explain differences in everything from gender and age to emotions.

  That kind of thinking just isn’t supported by science.

  But let’s be clear: beliefs that seem silly now used to be considered state-ofthe-art. So the intention isn’t to belittle the medical practices of the past. The body of knowledge in medicine is continuously growing and changing. The state-of-the-art continuously evolves, as it should.

  But once new evidence becomes irrefutable, there’s a responsibility to act on it. Otherwise, health care providers might still be giving patients tobacco enemas.

  Wait…tobacco enemas? In the late 1700s, the medical world was divided on the best way to revive a patient who had stopped breathing. You’ve likely heard the expression, “He’s just blowing smoke up your arse.” Meaning, he’s flattering you…giving an insincere compliment.

  But back in the day, literally blowing smoke up a patient’s rectum through a long tube was considered a legitimate medical procedure performed by doctors.71, 72, 73 Actually, it was considered a standard treatment for drowning victims. In fact, some of the greatest minds in the healing arts were fervent believers in the value of this practice. (Although, to be fair, many physicians believed it was better to blow air directly into the mouths of patients—even back then.)

  Figure 2.4: Smoke Enema: Depiction of how patients were resuscitated in the 1700’s.

  Clearly, it’s universally accepted today that the best practice for resuscitation is to use assisted ventilation to pump air into people’s lungs when they stop breathing. No one would try to use a tobacco enema to get a patient breathing again now. Of course, science doesn’t support that approach.

  In the same way, some people still believe compassion is a nice to have, even though there is abundant data that shows it’s essential for quality health care. So what about you? Will you forgo the use of compassion despite the evidence? Or will you join those that embrace the need for it?

  It’s up to you to decide after you review the evidence in the pages to come. It is important to recognize that the data to follow are not what we think, nor what we believe. Rather, it is what we found.

  CHAPTER 3:

  The Physiological Health Benefits of Compassion

  “In God we trust; all others must bring data.”

  —W. Edwards Deming

  Before considering the evidence for health care provider compassion and its effects on individual patients, let’s first take a high-level look—a thirty-thousand-foot view—at the data on human connection and health outcomes to exami
ne trends in the general population. Much like an epidemiologist (a scientist who studies the incidence of disease in populations) might approach the topic.

  If there appears to be a link between meaningful interpersonal relationships and health in the general population, it makes sense that there could also be similar effects from human connection and relationships with patients in the health care environment. So we will begin our journey through the data by starting at the macro level, and then we will zoom in on the effects at the patient level.

  The Link between Human Connection and Health

  Compelling data on the health benefits of interpersonal relationships can be traced back decades. In 1988 researchers from the University of Michigan published a landmark paper entitled “Social Relationships and Health” in the prestigious journal Science.74

  They analyzed the available evidence from population-based studies and concluded that, after taking into account people’s baseline health status, there was an increased risk of death among persons who have a low quantity (or low quality) of personal relationships. They also concluded that social isolation is a major risk factor for dying from a wide variety of causes:

  “Social relationships, or the relative lack thereof, constitute a major risk factor for health–rivaling the effect of well-established health risk factors such as cigarette smoking, blood pressure, blood lipids (cholesterol), obesity and physical activity”

  —House et al. 1988

  For the first time, it was beginning to become clear: loneliness kills.

  Loneliness kills.

  Put another way by a scientist who studies emotions, “Such an existence is too expensive to bear. When launching a life raft, the prudent survivalist will not toss food overboard while retaining the deck furniture. If somebody must jettison a part of life, time with a mate should be last on the list: [one] needs that connection to live.”75

  Loneliness and social isolation are not necessarily the same thing. Some people can be socially isolated and not feel lonely. For instance, some may consciously choose a hermit-like existence. Conversely, one can be surrounded by lots of people and feel desperately lonely, especially if the relationships one has are not meaningful.

  Loneliness, therefore, is the subjective experience of isolation (i.e., perceived isolation). It’s the discrepancy between one’s desired and actual level of human connection.76 So it’s not just the quantity of relationships, it’s also the quality that matters.

  Since that sentinel publication in Science back in the late 80s, numerous other rigorous, large-scale analytical studies have confirmed the link between human connection and risk of death from all causes.77, 78, 79, 80 For example, researchers from Brigham Young University analyzed 148 published research studies (involving more than 300,000 participants across a wide variety of health conditions) and found that having meaningful relationships was associated with 50 percent higher odds of survival.77

  They also found that in terms of mortality risk, a lack of meaningful relationships was comparable to the risks of smoking and alcohol abuse and worse than obesity and high blood pressure. In another study analyzing 70 published papers specifically focused on the risks of loneliness, the same research team found that being lonely was associated with 26 percent higher odds of early death.78

  In a longitudinal study supported by the National Institutes of Health (NIH) of 1,604 elderly persons, with six years of follow-up, researchers from the University of California San Francisco found that being lonely was associated with a 50 percent higher risk of decline in functional status (e.g., activities of daily living) and death.80 In yet another study of an elderly population, researchers from Harvard Medical School learned that being lonely was associated with a subsequent decline in cognitive function.81

  We can have confidence in these results because all of these studies used rigorous methodology and adjusted the analyses for factors that could be potential confounders, i.e., factors that might give rise to alternative explanations to the conclusion. This minimizes the chance that confounders impacted the results of these studies in a meaningful way. So it wasn’t just a case of the subjects being alone and, for example, less safe, thereby increasing the chances that they would die. Their decline—and death—didn’t occur because they were alone, it was because they were lonely.

  There are also compelling data in the heart disease literature to support these findings about the relationship between emotional support and death. A Yale study published in Annals of Internal Medicine studied this in 194 patients who survived a heart attack.82 Prior to discharge from the hospital, the researchers interviewed the patients and collected data on their emotional support at home.

  Recovery from a heart attack can certainly be tough, both physically and emotionally. The researchers’ hypothesis was that having emotional support from close relationships would enhance recovery from the heart attack and help keep them alive long-term.

  Heart attack patients with a lack of emotional support had three times higher odds of death.

  What they found is that 39 percent of all the patients they studied died within six months of the heart attack, and patients with a lack of emotional support had three times higher odds of death compared to patients who had emotional support. And that was after adjusting the analysis for demographics, marital status, living arrangements, medical history, physical health status, and the presence of depression.

  Emotional support appears to be essential…even for survival. It takes close relationships—ones that are meaningful—to help heal a heart that is literally broken.

  Loneliness is a Threat to Public Health

  The evidence is overwhelming. From a public health viewpoint, loneliness needs to be included on the list of health risk factors for the population, along with physical inactivity, obesity, poverty, environmental exposures, violence, and lack of access to health care. It’s a legitimate public health problem.

  Accordingly, the World Health Organization now considers “social support networks” to be a vital determinant of health.83 A recent article in the New York Times called the health effects of loneliness “a growing epidemic.”84

  In perhaps the most striking sign of the degree of alarm in the public health world, the U.K. government just appointed a Minister for Loneliness.85 No, we’re not joking. The threat is real and growing.

  But it’s not all bad news. In fact, it’s quite the opposite. Just as there is strong evidence that loneliness can be harmful to one’s health, there is also evidence that meaningful human connection can have beneficial effects.

  In what is likely the longest running scientific study ever conducted (eighty years and still ongoing), the Harvard Study of Adult Development began tracking the health of 268 Harvard sophomores, as well as a group of Boston teenagers, beginning in 1938 and checking in with them regularly over time. (Note: all the original study subjects were men because Harvard was still all male back then).

  The researchers followed the trajectory of their lives, with the aim of identifying the key factors responsible for good health and happiness. Only a few of the people initially enrolled in the study are still alive, but the results over the years paint a clear picture of the importance of human connection in health, vitality, and longevity.

  Dr. Robert Waldinger, the current study director and the fourth to hold that title, who is a psychiatrist at Massachusetts General Hospital and professor at Harvard Medical School, summarizes it like this:

  “Good relationships keep us happier and healthier…and loneliness kills. When we gathered together everything we knew about them about at age 50, it wasn’t their middle-age cholesterol levels that predicted how they were going to grow old, it was how satisfied they were in their relationships. The people who were the most satisfied in their relationships at age 50 were the healthiest at age 80.”86

  Meaningful human connection was in fact protective. But how? Although many might agree that humans are by nature a social species, what is the mechanism by whic
h human connection can impact our health?

  The short answer is that we don’t know yet, at least not entirely. The mechanisms appear to be extremely complex, but many researchers have identified at least one common thread: stress.

  Being lonely causes a similar response in the body as being under extreme stress all the time. For example, it raises the level of a stress hormone called cortisol circulating in the blood, which can play a role in chronic inflammation and subsequent development of cardiovascular disease.

  Also, without meaningful human connection to balance one’s stress, loneliness results in activation of the part of the nervous system called the sympathetic nervous system. It is the “fight or flight” response that gets turned on when you are experiencing a threat of harm.87

  This makes sense because research from the University of Chicago has also shown that loneliness predicts a rise in blood pressure over time, and a recent meta-analysis of 23 research studies found that loneliness is associated with a 29 percent higher risk of coronary artery disease and a 32 percent increase in the risk of stroke.88, 89

  Here is another mechanism of loneliness: its effect on the immune system. In a study sponsored by the NIH, researchers from Carnegie Mellon University studied the immune response to influenza (flu) vaccine among freshmen undergraduate students and its relationship to students’ level of loneliness.90 They did this both at the beginning of the study and over the course of the semester in which they received the flu vaccine.

  Then they measured the level of antibodies against the flu virus in the students’ blood, which is a readout of building immunity to the flu in response to the vaccine. What they found was striking: Students who were lonely had the lowest levels of antibodies against the flu virus. In other words, they had the weakest immune response to the vaccination; their bodies were less likely to fight off the flu virus.