Compassionomics

  Compassion Builds Trust

  Do all of the data on the effects of having a trusted other have important implications for health care? What if health care providers are meeting a patient for the first time? Can they really play such a meaningful role for a patient?

  Actually, yes. When seeking health care, most patients confer trust in physicians, nurses, and other caregivers when they make the choice to place their health and well-being in their hands. Without trust, why would a patient ever take a health care provider’s advice or adhere to his or her recommendations? Patients want to give trust to their providers.

  But here is the catch: Trust is not automatic. A health care provider must build that trust, and one of the ways to rapidly build trust is through compassion. There is ample evidence on this in the biomedical literature.

  For example, in a study of 550 outpatients, researchers at Michigan State University found that patient perception of physician compassion was associated with higher trust in the physician.120 In a NIH-supported study of hospitalized patients, researchers at University of California San Francisco found that compassionate responses to patients by the physician had a measurable and statistically significant effect on patient rating of trust in the physician.48

  Multiple studies have shown an association between better patient experience and connecting with or trusting the physician. So a health care provider that is compassionate can readily become a trusted other for a patient. And therefore, a health care provider may be a person whose compassion and emotional support can affect patients’ experience of pain. The trust may not be automatic, but the bar is fairly low to earn it.

  In one of the first studies that demonstrated a health care provider’s compassion can actually change what is happening in a patient’s brain, researchers at Michigan State University performed a functional MRI to measure brain activity in people that underwent an experimental painful stimulus.121 The subjects were recruited from the waiting room of a primary care clinic.

  All of the study participants underwent a medical interview from a physician and were randomized to one of two study groups. In the first group, the medical interview was patient-centered, with an emotional support focus and included a 21-point compassionate care procedure from the physician.

  In the second group, it was a medical interview without any expression of compassion from the physician. Then the subjects were given a painful stimulus (electrical stimulation) while simultaneously being shown an image of the physician at the same time that a brain scan (functional MRI) was done.

  What they found was that the compassion group experienced less pain, as evidenced by 47 percent less activation in the region of the brain for experiencing pain. So the connection they made with the compassionate physician—who they just met—actually buffered the pain.

  What does this mean? Compassion from the physician imprinted upon the study subjects. The trusted other didn’t need to provide real-time compassion, such as hand holding. The compassion literally echoed from the initial visit into the later (painful) part of the experiment.

  You may ask: Besides all the experimental studies, and the study of the compassionate care of the anesthesiologist for surgical patients, are there other studies showing that compassion can buffer a patients’ pain in a real-world clinical setting? The answer is yes.

  Compassion Reduces Back Pain

  Low back pain is one of the most common reasons for seeking medical care in the U.S. Eighty percent of people will experience significant low back pain at some point in their lifetime, with 10 to 20 percent of those at risk for developing chronic low back pain and disability. Thus the scope of the problem is huge, and the toll that it takes on people is immense. Those individuals often are so debilitated by pain that they need to stop working, turning to workers’ compensation funds or disability benefits to get by.122

  Here are some noteworthy study results to consider: In a rehabilitation medicine randomized controlled trial in patients with chronic low back pain, researchers randomly assigned patients to receive either conventional physical therapy or physical therapy plus an “enhanced therapeutic alliance,” in which the therapist intentionally used a compassionate tone of voice and nonverbal behaviors—like eye contact and touch—plus statements of compassion such as, “I can understand how difficult low back pain must be for you.”123

  The outcome measures for the study were a well-validated scale of pain intensity, reported by the patients prior to and after therapy, as well as “pressure pain sensitivity,” which is the standard quantitative method for measuring low back muscle tenderness in pain research. Basically, it is a calibrated instrument that precisely measures how hard you can press on sore back muscles before the patient reports having pain.

  What the researchers found is that patients randomly assigned to the compassionate therapeutic alliance had more than double the pain relief from physical therapy, compared to physical therapy without the compassion enhancement. Further, following therapy, researchers could also press significantly harder on the patients’ sore backs without eliciting pain if they were in the enhanced compassion group.

  In another rehabilitation medicine study of two hundred patients, researchers tested the association between the quality of the patient-doctor interaction (from the patients’ perspective) and the amount of pain patients were still in six months later.124 Specifically, they measured the physicians’ affective (or emotional) quality of the interaction, a key part of which was physician compassion.

  They measured the patients’ pain and disability at the beginning of the study and again at six months. What they found was that when patients perceived high quality interaction with the physician, the improvements in pain intensity, pain frequency, and the level of functional impairment specifically due to pain were all more than double the improvements experienced by patients who perceived low quality interaction with the physician.

  So if health care providers can make a sizeable dent in all that pain, suffering, and lost productivity with compassionate care, shouldn’t they do it?

  Compassion Reduces Headache and IBS Pain

  If the evidence of the effect of compassion on back pain isn’t convincing enough, then consider the data on headaches.

  In another interesting pain study, researchers tested the association between physician compassion, as assessed by patients, and the pain experienced by patients who suffer from migraine headaches.125 They recruited patients going to neurology clinics for migraine treatment and measured the patients’ degree of disability from migraines at the time of seeing the physician and then again ninety days later, using a standardized, well-validated scale.

  They also measured the patients’ assessment of the physicians’ compassion using another well-validated survey that is the most commonly used survey instrument in compassion science research to date. It’s called the CARE measure (the acronym stands for Consultation And Relational Empathy).

  What they found was a very high level of correlation between the physicians’ performance on the CARE measure and the decrease in migraine headache-related disability experienced by the patients. So the more compassion, the lower the pain. Specifically, there was a high level of correlation between the CARE measure and the number of days with a headache, as well as intensity of the headache pain.

  One of the most interesting studies pertaining to impact on pain is in a disease called irritable bowel syndrome, or IBS. This is a chronic, potentially debilitating intestinal disorder that causes abdominal pain (along with gas, diarrhea, and constipation). It’s a fairly common problem; for example, it’s the reason for nearly a third of patient referrals to gastroenterologists.

  People with IBS can experience great suffering. There are few treatments and those that exist are only partially effective. As a result, and in an attempt to get some sort of relief, patients often turn to “complementary medicine” treatments (sometimes also called “alternative medicine”) such as acupuncture.

  But w
hat if compassion is actually more powerful than either conventional or alternative therapies? In a randomized controlled trial from Harvard Medical School, researchers randomly assigned 262 patients with IBS to one of three treatment groups: (1) nothing (control group)—observation only; (2) acupuncture; or (3) an “augmented patient-provider relationship,” (i.e., augmented by human connection through warmth, attention, and compassion).126 For example, compassionate statements included “I can understand how difficult IBS must be for you.”

  In this third arm of the study, the providers were not allowed to give any other potentially effective treatment, like extra education, counseling, or use of a technique called “cognitive behavioral therapy.” The only things in the intervention were human connection and compassion.

  Then they measured the effects of each of these interventions on the patients’ symptom relief, symptom severity, and quality of life. Compared to observation alone, acupuncture helped a bit. But the really striking results were in the group that experienced the augmented relationship with the health care provider.

  The warmth and compassion from providers made an enormous difference! Three weeks later, the proportion of patients in the augmented human connection group that had adequate relief of symptoms, including abdominal pain, was double the proportion of patients with adequate relief in the observation-only control group. For these patients with IBS, compassionate care was a game changer.

  Another Thought to Consider

  Considering all of the data just reviewed in this chapter regarding compassion and pain—from experimentally induced pain, to post-operative pain, to back pain, to headache and IBS—showing such dramatic impact and published in distinguished scientific journals, how is it that these findings are not better known? With the number of deaths annually in the U.S. from opioid overdoses now surpassing the deaths from car crashes, deaths from guns, and deaths from the peak of the HIV crisis, shouldn’t medicine be taking a closer look at caregiver compassion as a possible component of the treatment modalities to lower opioid use, as in the studies described above?127

  So why haven’t all of these studies on compassion and pain been pulled together before? This is an example of the purpose of this book. Despite all these data being previously available in the scientific literature, all the dots had not been connected together to paint the overall picture.

  Compassion Improves Functional Impairment

  Intractable pain can certainly limit a person’s ability to function properly. So it’s not surprising that the studies above—those that showed caregiver compassion can impact the pain that patients experience—also showed that compassion improved patients’ overall functional status. That’s what they found in the back pain study, the rehabilitation medicine study, the migraine headache study, and the irritable bowel syndrome study.123, 124, 125, 126

  But there is also research on the impact of compassion on functional impairment for reasons other than pain. A synthesis of all the available data on the topic of the therapist-patient relationship in physical rehabilitation research found that a therapeutic alliance that includes an affective (i.e., emotional) bond is associated with better functional outcomes for patients.128

  Compassion for others is not just what you say.

  Among these, one study stands out from the crowd in both scientific rigor and wow factor—and it shows that compassion for others is not just what you say. This research was supported by a grant from the National Science Foundation and was a collaborative effort between researchers at Harvard and Stanford Universities.129

  In it, they studied the impact of non-verbal communication (i.e., “body language”) of physical therapists on functional outcomes for elderly patients admitted to the hospital. An admission to the hospital can be a major setback for anybody, but especially for elderly patients. After a bout of illness or injury, elderly patients often need some physical therapy in the hospital so that they can function well enough to be discharged. This study tested the impact of therapist compassion (or lack thereof) in that scenario.

  The study was rock solid in terms of scientific methodology. The researchers videotaped the elderly patients’ physical therapy sessions. Trained judges watched the video clips of the therapists’ behaviors and analyzed every move they made using validated scales for categorizing body language.

  They assessed the functional status of the patients too, not just their physical functioning—such as their ability to do activities of daily living without assistance (e.g., walking, getting to the bathroom)—but also their cognitive functioning at the time of admission to the hospital, the time of hospital discharge, and three months after hospital discharge.

  Here’s what they found after analyzing the data: Non-verbal “immediacy” (e.g., leaning in toward the patient, less interpersonal distance, making direct eye contact, and facial expressiveness, such as smiling and nodding) had a significant association with better patient functional outcomes on both physical and cognitive functioning. Likewise, non-verbal “distancing” behaviors (e.g., keeping at a distance, looking away, no eye contact, and a lack of facial expressiveness) by the therapists were associated with worse physical and cognitive functioning in the elderly patients.

  When we show people compassion and make an interpersonal connection, our non-verbal communication has to be one of immediacy rather than distancing. That’s how compassion works. You cannot show compassion for others if you seem distant.

  Clearly, compassion is not just about what you say, but also what you are communicating to people without using words. And this research shows that the effects can be profound.

  Compassion Improves Endocrine Function

  What’s the most common cause of amputation? It may surprise you to learn that traumatic injuries are only responsible for 5.8 percent of lower limb amputations in the U.S.130 The most common cause of amputations is actually diabetes.131

  Diabetes is one of the foremost public health challenges facing health care today. An estimated thirty million people have diabetes in the U.S. alone (approximately nine percent of the population).132 The estimated health care costs of diabetes in the U.S. are $327 billion annually.133

  But diabetes is equally devastating at the personal level. The human toll of diabetes includes the development of heart attacks, stroke, and kidney failure, in addition to complications from diabetes itself, which require frequent admissions to the hospital.

  Due to the effects of uncontrolled blood sugar on the nervous system, patients with diabetes are prone to developing very painful conditions in their legs. Uncontrolled blood sugar can also damage blood vessels over time and impair blood flow to the lower legs, sometimes requiring amputations. Diabetes is a common cause of major disability, and it is often an underlying cause of early death. In fact, in 2015 diabetes was the seventh leading cause of death in the U.S.134

  If it isn’t clear enough from these facts, it’s important to do what you can to prevent yourself or your loved ones from developing diabetes. For those that have diabetes, it’s vitally important to treat it appropriately to make sure you avoid the complications that can arise.

  Unfortunately, diabetes can be very challenging to treat. Although there is no cure for diabetes, control of the disease (and, specifically, control of the patients’ blood sugar) is possible. But doctors need all the help they can get. If there was a simple and inexpensive way to aid blood sugar control in patients with diabetes—even if the effects were only modest—it would certainly be worth a try. So can compassion make a difference? Yet again, the answer is yes.

  Although many of the studies in the pages to follow will include measurements of health care provider compassion from the patient perspective, it also can be informative to measure health care providers’ own beliefs about compassion, because their values and beliefs most definitely influence their behavior toward patients. Accordingly, researcher Dr. Mohammadreza Hojat and his colleagues from Sidney Kimmel Medical College at Thomas Jefferson University in Philade
lphia developed an interesting research tool (survey) to measure the importance of compassion from the health care provider perspective.135

  Although the researchers called it the “Jefferson Scale of Empathy” (rather than compassion), what they were measuring definitely fits our working definition of compassion, as described in Chapter 2. So we’ll consider it to be a compassion scale from here on.

  Here’s how the tool works: It’s a 20-question survey given to health care providers that assesses their beliefs about the importance of understanding patients’ feelings and whether or not compassionate attentiveness to patients’ emotional states can influence treatment success and other outcomes (including making the patient feel better). It also measures capacity to communicate the understanding of patients’ emotional state with an intention to help.

  Basically, this research methodology measures whether or not health care providers believe that a caring relationship with patients makes a meaningful difference. The scale is very methodologically sound, and it has been well-validated.

  Now let’s look at two of their studies that measured the compassion scale in physicians who were treating patients with diabetes, to see if there was a link with better outcomes. In their first study, they examined data for 891 patients with diabetes under the care of 29 different family physicians at Thomas Jefferson University.136 All of the physicians completed the compassion scale survey. Then, based on the results, the researchers placed the physicians into one of three groups: high, moderate, or low compassion.