Compassionomics

by Stephen Trzeciak

  The lonely students also reported greater psychological stress and had higher levels of circulating cortisol. But the results of the research are clear: After accounting for all other potential confounding factors, being lonely was associated with worse immune function and could hurt one’s resistance to infection.

  These data on immune function are corroborated by the findings in another Carnegie Mellon University study published in JAMA.91 In this study, researchers assessed the social relationships of 276 volunteers by measuring the number of activities with a spouse, parent, friend, workmate, or other close connections.

  Then the participants were given nasal drops containing rhinovirus (i.e., the common cold virus) and were monitored to see if they developed a cold. The researchers also measured physiological response to the cold virus, such as how much mucous they produced and how well the subjects were clearing the virus from their nasal passages.

  A lack of human connection can increase susceptibility to the common cold.

  What they found is that, compared to people with robust social connections, people with social isolation (i.e., the least human connection) had increased susceptibility to the common cold, more mucous production, and a lower clearance of the virus from their nasal passages. Those lacking in human connection were not as resistant to illness.

  Eye-opening research from the University of California Los Angeles has found that loneliness can also affect our genetics. Specifically, these researchers looked at gene expression in circulating white blood cells, which are involved in the immune response.

  By upregulating (i.e., “turning on”) and downregulating (i.e., “turning off”) various genes in the immune system, loneliness can produce a state of chronic systemic inflammation (activation of inflammation throughout the body).92 Chronic systemic inflammation has been linked with a myriad of adverse health effects, not only the development of cardiovascular disease, but also arthritis, diabetes, dementia, and many others.

  Human Connection Matters

  So yes, loneliness can have devastating effects on health. But compassion can be the antidote. The scientific evidence suggests that the chronic inflammation we just talked about (and perhaps the health effects that can result from that over time) can actually be reduced by someone who cares.

  Research from Northwestern University that studied 247 adolescents and their parents found that high parental compassion is not only associated with their children having lower emotional distress, but their children also had significantly lower circulating blood markers of systemic inflammation!93

  How often have you heard about how stress can worsen health conditions? Probably quite often. You may have already been aware of the connection between stress—specifically emotional distress—and its potential adverse effects on your health. This has been known for decades, perhaps most notably in cardiovascular disease.94

  So the notion of a “mind-body” connection, where one’s thoughts, beliefs, and experiences (e.g., their experience of loneliness) affects their biology and physical health, is probably not hard to believe. But one thing you may not know is that while the link with adverse health effects has been known about for decades, it was only recently that researchers could actually see this connection. They saw it on brain scans.

  Here’s how it happened: In a Harvard study funded by the NIH and published in The Lancet, researchers used functional MRI brain scans to measure the activity in a region of peoples’ brains called the amygdala, and then they followed up with them over time to see what was happening with their physical health.95

  The amygdala is a structure deep inside the brain, about the size of an almond, where we process emotions, and it’s also an “alarm system” involved in the fight-or-flight response. It’s activated under conditions of extreme stress, including emotional distress, and loneliness can be one of these triggers.

  How does the functional MRI fit in here? It takes a look inside the brain to see what areas light up due to subtle increases in blood flow. It shows researchers which areas of a patient’s brain are firing at any given moment.

  The people recruited for the study were healthy at the time and not under any particular distress at the moment, so whatever brain activation they had in the amygdala was presumably the baseline stress (or distress) that they carry around with them every day. (As we noted in Chapter 1, you never really know what kind of pain people are carrying around, and of course we can’t do functional MRI on every person we meet to try to figure that out.)

  What this Harvard study found was striking. The baseline activation in the amygdala region of the brain predicted not only the amount of inflammation they had going on in the blood vessels throughout their body (the researchers measured it), but it also predicted the subsequent development of serious cardiovascular disease events, like heart attacks and strokes, over time.

  So it may not take much to convince you that there is a mind-body connection, due to decades of reports about the health outcomes, but now we have brain scans that can help explain and actually visualize the neurobiology behind it all.

  And here is the most dramatic example of the mind-body connection that exists: It’s a condition called Takotsubo cardiomyopathy (also known as “stress cardiomyopathy” or “broken heart syndrome”). It’s a very serious cardiac emergency that (thankfully) is uncommon, but seeing a case of it can be among the most unforgettable events in one’s medical career.

  You will read about an especially dramatic case of this condition later, but here’s how it works: Takotsubo cardiomyopathy is commonly triggered by extreme emotional stress, like a relationship ending or a death in the family. The name Takotsubo comes from the Japanese word for octopus trap (which is apparently what the heart looks like on echocardiography during this condition).

  Here’s what happens to people: When doctors use an echocardiogram to look at the heart pumping in a Takotsubo cardiomyopathy patient, they see that the main chamber of the heart—the one that is responsible for pumping blood out to rest of the body—takes on an abnormal shape, thought to resemble a fishing pot by those who first described it in the medical literature.

  In this condition, the heart suddenly becomes unable to pump blood effectively, and the patient suddenly goes into a state of heart failure and life-threatening shock. When this happens, the first thing that the doctors typically think of is the most common cause of sudden heart failure: a heart attack.

  But when they look for clogged heart arteries they do not find any. The blood vessels are wide open. How and why it occurs is not totally understood yet, but one piece of it appears to be a spike in circulating hormones called epinephrine and norepinephrine that are released by the body in response to stress, such as severe emotional stress.

  It can be rapidly fatal. Literally, the person can suddenly collapse or even drop dead. Have you ever heard that, after the death of a loved one, someone suddenly “died of a broken heart?” That’s why Takotsubo cardiomyopathy is also nicknamed “broken heart syndrome.” It actually happens, and it has been well described in the medical literature (e.g., the New England Journal of Medicine).96

  So, you might now ask: “What does all this data on loneliness and the mind-body connection have to do with compassion?”

  The answer is: everything.

  The most obvious reason is that reaching out to lonely people with compassion fosters human connection that can make a lonely person feel less alone. In one of the most striking compassion research studies you will read about later, a randomized trial of a compassion intervention for cancer patients at Johns Hopkins University, one of the key elements of the intervention was this message from the physician to the patient.

  “I know this is a tough experience to go through and I want you to know that I am here with you. We are here together, and we will go through this together. I will be with you each step along the way.”97

  Seriously ill people go through very dark times and walk through dark places where they may feel all alone
or abandoned. More than ever before in their life, they need to know that someone is willing to walk with them.

  Now that you understand all the scientific data for the dramatic effects of loneliness on health outcomes and the effect it can have on their health (especially when someone is sick), will you be more willing to walk with a patient who feels all alone? Will you be willing to ask if they feel alone? We may never know if we neglect to ask. Hopefully, now you know how much it matters.

  The data on the health effects of loneliness, human connection, and the mind-body connection provide the context. They set the stage for all of the data on compassion that will follow and lay the groundwork for the profound effect of human connection on human health.

  It’s important to see this “big picture” first, before reviewing the data that is specific to compassion for others. If human connection was not a determinant of health, then there would be no scientific rationale for believing that modulating human connection (through compassion) would be meaningful for health. But now that we know human connection is strongly associated with better health, it makes sense that augmenting human connection with a compassion intervention could result in meaningful change.

  For good health, human connection matters.

  The data we’ve reviewed so far has laid an important foundation, a starting point to begin to open our minds to the possibility that how we relate to one another—how we connect or fail to connect—can, in fact, impact one’s health in meaningful ways. For good health, human connection matters.

  That’s powerful. And it is obviously rooted in very rigorous scientific evidence. It’s not mushy. It’s not soft. It’s science. It’s part of that overlap between both the art and science of medicine, areas that previously were believed to be completely separate and distinct.

  But now that we know human connection matters, what is the evidence that compassion matters? Next, let’s zoom in specifically on the power of compassion for patients.

  Compassion Heals

  Dr. Alann Solina is an expert in putting people to sleep. To be fair, he’s also an expert in waking them up. That’s what anesthesiologists do.

  As chief and chair of the Department of Anesthesiology at Cooper University Health Care and Cooper Medical School of Rowan University, Dr. Solina has provided anesthesia to more than 25,000 patients undergoing surgical procedures over the course of his career. The method by which anesthesiologists put people to sleep and make sure they have their pain minimized as much as possible is straightforward. They use drugs. At least that’s what they teach aspiring anesthesiologists in their training.

  There is no doubt that effective drugs are at the core of providing effective anesthesia for perioperative patients. But are drugs the only effective therapy? In Dr. Solina’s experience, the answer is most definitely, “No.”

  Dr. Solina’s leadership of the Department of Anesthesiology is characterized by being an “in the trenches” leader. That is, while carrying a huge administrative load in running the department, he also continues to maintain a very active clinical practice on the front lines of medicine. Why? “Among all that I do, taking care of patients at the bedside is what gives me the most fulfillment,” he says.

  When asked what specific aspect of clinical practice brings him the most fulfillment, his answer is simple: “Connecting with patients prior to surgery, building rapport, providing them with reassurance, and, most of all, treating them with compassion.” Why? Because he sees the profound effect that it can have.

  If you are a patient, having surgery can be hard. There can be tremendous anxiety in the days leading up to surgery, and that can skyrocket when you are in the pre-op area waiting to be wheeled into the operating room. In addition, patients having surgery may have an underlying condition associated with major suffering, so they’re looking for relief. That moment of waiting for surgery can be one of the most vulnerable times in a person’s life.

  In that moment, Dr. Solina has observed, compassion is essential. And it works.

  Works? What does that mean? Works how?

  Dr. Solina has made an astute observation, one that is consistently borne out time and time again, in his decades of experience. “When I am able to build a bond with a patient ahead of surgery, where I show that I care about them and they put their trust in me, I find that they actually need a lower amount of sedatives ahead of surgery and oftentimes none at all. When we wheel them into the operating room, they are much more likely to be peaceful and calm.”

  He has come to this conclusion after decades of close personal observation. “It’s not just about the drugs and the anesthetic agents; it’s also about the anesthesiologist,” he reports. When he makes a compassionate connection with a patient who is about to be wheeled into the operating room, he actually becomes part of the therapy.

  Is Dr. Solina overreaching? Are his observations a bias towards overvaluing his relationships and interactions with patients?

  What do the scientific data say? There are rigorous experimental data (actually, clinical trials published in two of the most highly regarded medical journals worldwide) supporting exactly what Dr. Solina has been observing over the course of his career in academic medicine.

  The Role of the Healer as Therapy

  In the 1960s, at Massachusetts General Hospital in Boston, researchers in anesthesiology from Harvard Medical School conducted two experiments in patients awaiting surgery. They published the results in The New England Journal of Medicine and JAMA.98, 99

  In these studies, the researchers tested an unconventional hypothesis, one that was decades ahead of its time: Could the anesthesiologist be the agent of therapy? Could he or she actually be the treatment? They tested the hypothesis that a compassionate connection from the anesthesiologist would have a meaningful and measurable effect on patients.

  These studies were randomized controlled trials: a research design in which half of the patients were assigned, at random, to a new experimental therapy, and the other half of the patients did not get the experimental therapy (i.e., the control group). A randomized controlled trial is considered the most rigorous type of study from a scientific perspective, because it is the best way to minimize the risk of bias or confounding of the study results.

  What was striking about these two studies, however, was that the experimental therapy was not some new anesthesia drug or high-tech approach. Actually, it could be considered “old school.”

  In these studies, half of the patients were randomly assigned the experimental therapy that consisted of a special (extra) visit prior to surgery from—you guessed it—the anesthesiologist. The purpose of the extra visit was explicitly to build doctor-patient rapport.

  The anesthesiologist’s compassion for the patients was a cornerstone of the reassuring and bonding experience. In fact, the researchers called these patients the “special care” group. One of these studies compared the effects of the anesthesiologist’s special care versus the effects of a powerful sedative (a drug called pentobarbital) administered just prior to surgery.

  The results were striking. The researchers found that the patients who were administered pentobarbital were drowsy just prior to surgery, but they were not calm. On the other hand, patients in the special care group were calm, but not drowsy.98

  How reliable were these results? The research used a predefined methodology to standardize the assessment of calm and drowsy, used a randomized trial design, and was published one of the leading biomedical journals in the world. The results were highly statistically significant. Therefore, we can have high confidence in the findings.

  So this experiment demonstrated through science that a rapport-building, compassionate connection with an anesthesiologist before surgery can make patients calmer as they are about to undergo surgery, necessitating less sedatives. In fact, the researchers found that to achieve what they prospectively defined as “adequate sedation,” the effect of the special care pre-operative visit from the anesthesiologist was more than d
ouble the effect of administering pentobarbital. You will recall that this is exactly what Dr. Solina has observed about the power of compassion for patients over decades in real-world practice!

  But that’s not all. In the second of the two experiments at Mass General, they tested the effects of the special care intervention (i.e., the same pre-operative visit from the anesthesiologist) on patients’ post-operative pain.99

  Equally as striking as the results of the first experiment, in the second experiment they found that patients randomized to the special care visit from the anesthesiologist prior to surgery had 50 percent lower requirement for opiate pain medication (e.g., morphine) following surgery. Interestingly, the patients who were randomly assigned to special care also had a statistically significant decrease in their length of stay in the hospital following surgery.

  In 2015, another randomized, controlled trial found essentially the same effects on post-operative pain.100 Researchers randomized 104 patients about to undergo surgery to one of two treatment arms, either the usual pre-operative care, or pre-operative care with enhanced compassion.

  In this study, rather than an anesthesiologist, the people delivering the pre-operative care were surgical nurses. For the enhanced compassion intervention, the nurses underwent specific training to give compassionate responses to patients’ emotions through explicit compassion-focused behaviors.