Compassionomics

by Stephen Trzeciak

  They then reviewed the data for blood sugar control among these patients with diabetes, specifically the patients’ hemoglobin A1c levels in the blood. It’s a blood test that shows what a patient’s average blood sugar level has been over the past few months.

  Among patients with diabetes, the odds of optimal blood sugar control were 80 percent higher with high compassion physicians.

  What they found was that patients of high compassion physicians were significantly more likely to have optimal blood sugar control, compared to patients of low compassion physicians. In fact, the odds of optimal blood sugar control were an astounding 80 percent higher! Statistically, the researchers ran tests on the data to make sure that the association between compassion and better blood sugar control was not influenced by patient factors like age, gender, or health insurance status. So we can have confidence in the results.

  Interestingly, that wasn’t all. In these 891 patients with diabetes, the researchers found that high physician compassion also had 80 percent higher odds of optimal blood cholesterol control.

  Their second study in patients with diabetes was a bit different but, remarkably, even more compelling.137 In this study, these U.S. researchers took their physician compassion scale all the way to Parma, Italy. Why? To do a study of enormous scale.

  Italy has a national health service in which all people in the region around Parma who receive health services from the government have to select a primary care physician in the Local Health Authority. The researchers were able to tap into the Local Health Authority to enroll 242 physicians who completed the physician compassion scale. This allowed them to analyze data for all of their patients with diabetes: a whopping 20,961 patients in all.

  What they found was striking indeed. After breaking physicians down into high, moderate, and low compassion groups like they did in their earlier study, the researchers then analyzed the association between physician compassion and the most serious complications of poor blood sugar control—emergency conditions like diabetic ketoacidosis, or diabetic coma, that require admission to the hospital.

  Patients of high compassion physicians had 41 percent lower odds of serious diabetes complications.

  They found that compared to patients of low compassion physicians, patients of high compassion physicians had 41 percent lower odds of serious diabetes complications! So this large-scale study showed results that were even more remarkable than the Jefferson study. These were not just blood sugar levels that were better, these were the actual complications from high blood sugar. The reason why physicians track the blood sugar levels are to prevent complications. Complications are the endpoints that matter most.

  So what could the possible mechanisms be to explain effects on blood sugar? The short answer is that no one is precisely certain. But one possibility is that compassion affects patients’ physiology in such a way that it also affects how the nervous system influences endocrine function. (Refer back to our earlier discussion on how compassion can affect the nervous system and cardiovascular system.)

  That is, it can have a direct effect on the body in such a way that it minimizes extreme spikes in blood sugar, possibly through an effect on the levels of circulating stress hormones. Another potential mechanism is what we will discuss in Chapter 5 (better patient self-care).

  It’s possible that compassion for patients builds better rapport between doctors and patients, and this motivates patients to adhere to their medication regimen (e.g., insulin) more closely.138, 139 For example, sometimes patients will say that one of their motivations to adhering to what their physician prescribed is that they do not want to “let down” their doctor by not sticking to his or her treatment plan.

  Or sometimes compassion can help patients believe that better health is actually possible (rather than feeling hopeless), and this results in better adherence to prescribed therapy.138 All of these mechanisms could be responsible for the effects of compassion that we see in patients with diabetes, at least in part.

  But regardless of the mechanism, whether it is a direct effect on the body or it is causing patients to take better care of themselves, the association between compassion for patients and better control of diabetes is clear. Given the magnitude of the diabetes problem and the inherent challenges in treating diabetes, using more compassion in the care of diabetes patients should be a no-brainer.

  Compassion Helps Wounds Heal Faster

  For decades, scientists have known that psychosocial stress can slow the rate at which wounds heal. It was first demonstrated in a study published in The Lancet back in 1995.140 How does that work? In wounds, immune function and local tissue inflammation play a big role in regeneration and repair of injured tissues. Psychological stressors can work against proper immune function at the site of injury (called cellular immunity) and slow the healing process. In this sentinel research paper, the researchers from Ohio State University demonstrated this in a very scientifically rigorous way.

  Ten years later, in a follow-up study from the same group supported by a research grant from the NIH, the researchers tested whether emotional support from a trusted other could impact the rate of wound healing.141

  Here’s how they did it: They recruited 42 married couples who were free of any medical issues and admitted them to a research unit for 24 consecutive hours on two separate occasions. They used a standardized well-validated method to study early wound healing.

  First, they created the wounds by attaching suction cups to the forearms of the married couples and hooking the suction cups up to vacuum pressure for an hour. This created blisters on the forearm. Then the researchers popped the blisters. They checked the healing of the blisters once a day using a standardized validated technique.

  Basically, the blister wound was considered significantly healed when it stopped leaking fluid. Also, this method allowed the researchers to measure molecules in the blister fluid called cytokines that are part of the natural healing process.

  In the first 24-hour admission to the research unit, the married couples participated in a structured social support activity. They were encouraged to be emotionally connected with each other and talk about how they could grow their relationship. Then they were asked to tell the researchers the “story” of their relationship. (Sounds sort of like a marriage retreat?)

  In the second 24-hour admission, the tables were turned. This time they were asked to hash through the most conflict-producing topics in their marriage. They did not have any structured emotional support time; it was focused only on conflict. And it worked. The researchers were keeping track of “hostile” behavior by the married couples, and it was off the charts!

  What they found was that the time to wound healing was significantly shorter, specifically 17 percent shorter (five days to heal instead of six days), with the social support visit compared to the conflict visit. And that’s not all: The measured levels of cytokines in their blister fluid favored healing with the social support visit, but not with conflict. That helps to explain why the speed of healing was different. (It’s very interesting what people will subject themselves to in the name of science, isn’t it?)

  But what’s the evidence of human connection affecting wound healing in clinical medicine? Remember that randomized controlled trial of pre-operative compassion discussed earlier in this chapter? The one where the researchers randomly assigned pre-operative patients to usual care versus an enhanced compassion intervention from surgical nurses prior to having surgery?

  That’s the one where the patients’ pain scale ratings were cut by 50 percent in the patients randomly assigned to enhanced compassion.100 Well, they also measured wound healing, one month following surgery. They used a pre-defined, standardized, and well-validated scoring scale to assess proper wound healing.

  At one end of the scale was proper scar tissue formation, and on the other end of the spectrum was devitalized tissue indicating wound breakdown. The researchers found that patients randomly assigned to enhanced compassi
on had statistically better wound healing scores than patients randomly assigned to usual care. The pain that patients were experiencing at the site of the wound was also found to be statistically lower in the enhanced compassion group.

  Compassion Even Improves Symptoms of the Common Cold

  Earlier in the chapter, we reviewed the data on how human connection can impact the immune system and resistance to infectious disease. Specifically, we read how in the general population, human connection can be a factor in the immune response to the flu vaccine, gene expression producing chronic inflammation, and even resistance to the cold virus.90, 91, 92 Here’s another compelling study on the power of…hugs?

  In another NIH-funded study from Carnegie Mellon University that was published in the flagship journal of the Association for Psychological Science, researchers tested the power of hugs to combat the common cold.142

  It was a study of 406 healthy volunteers that assessed participants’ social support and, specifically, the number of hugs that they received over the preceding 14 days. Then they took a syringe containing the cold virus and shot it up their noses.

  Then they quarantined the volunteers and monitored them for the development of cold symptoms. What they found was that people with high stress and conflict in their life were more likely to develop an infection (as evidenced by viral replication, antibodies to the cold virus, and symptoms).

  That may not be surprising, based on the studies we reviewed earlier. But what was surprising was that the volunteer’s level of social support and, specifically, the number of hugs they received in the preceding 14 days, protected against the development of infection. In fact, 32 percent of the protective effect of social support against infection was directly attributable to hugs!

  But what is the clinical evidence that health care provider compassion for patients has a meaningful effect on their immune function?

  To answer this question, researchers from the University of Wisconsin-Madison, with support of the NIH, conducted a study in patients with, again, the common cold.143 A few pages back, we talked about the CARE measure, which is the well-validated survey that measures the compassion of the health care provider from the patient’s perspective.

  These researchers enrolled 350 patients presenting to a primary care office with the common cold. They asked the patients to complete the CARE measure for their physician and followed patients over time, measuring the duration and severity of their symptoms as well as a marker of the immune response (called interleukin-8) in their nasal passages.

  High physician compassion was associated with enhanced immune response, a one day decrease in duration of cold symptoms, and 15 percent decrease in cold symptom severity.

  Then they compared the outcomes for patients of the physicians with the highest compassion scores versus the patients of lower compassion physicians, as rated by patients. After accounting for possible confounding factors, they found that high physician compassion was associated with a doubling of interleukin-8 levels (indicating enhanced immune response), a one day decrease in duration of cold symptoms, and a 15 percent decrease in cold symptom severity. It appears that caring makes a difference…even with the common cold!

  Compassion Can Literally Keep You Breathing

  By now, you are beginning to see that science demonstrates the power of compassion for patients. Patients with medical crises like surgery, trauma, or a heart attack may have better outcomes. Patients with pain may experience relief. Patients with impaired function may recover more quickly. Patients with chronic conditions (e.g. diabetes) may have better control of their disease. Patients may heal faster. Patients may be less prone to infection.

  But one story really illustrates the power of compassion on a patient’s physiology: the ability to breathe. And, like all the data that appeared earlier, this story also comes from the medical literature. In fact, it was published as a case report.144

  On May 16, 1972, a 34-year-old man who was a few days out from abdominal surgery suddenly developed critical illness due to septic shock (i.e., a severe life-threatening infection) and was admitted to the ICU. He was clinging to life, literally. His organ systems were failing. He needed life support with mechanical ventilation.

  Surprisingly, he pulled through the acute phase in the ICU, but the fight of his life was just beginning. Although the sepsis did not kill him in those first few days, it dealt such a blow to his lungs and his strength that he simply could not breathe on his own, even after the sepsis resolved.

  He was stuck on the ventilator, totally dependent. Imagine laying in an ICU bed, flat on your back, not moving, not even being strong enough to take breaths for yourself. He had to have a tracheostomy (a potentially permanent breathing tube) surgically placed in his neck.

  He was unable to speak. His eyes watered. His lips quivered. His health was shattered. So was his spirit. In his mind he was consumed with thoughts of death and dying. He thought he would never breathe on his own again, permanently dependent on the machine.

  But, thankfully, he did make it off the ventilator. He even made it out of the hospital…120 days later. Eventually, he made a complete recovery.

  So what was the difference-maker that allowed him to pull through – to be strong enough to breathe on his own again? The answer was simple: the nurses.

  But not just any nurse, and not every nurse. It was a few special nurses that he considered his “angels.” After recovery, the man told his story:

  “After weeks of being on a ventilator in the ICU, I could tell right away when a new nurse came on duty at the change of shift and entered my room. I could tell within one minute whether or not the nurse cared.

  If it was a nurse who did not care, my heart would sink. My spirit was crushed. I lost my will, and I did not believe I would ever get off the ventilator. But if it was a nurse who cared, one of my ‘angels,’ I would instantly feel stronger. I believed I could beat this and breathe on my own again. Without my angels, I never would have made it. Their compassion is what saved me.”145

  Caring made a difference.

  Who was the man stuck on the ventilator who told his story in this published case report?

  It was Dr. Edward D. Viner, who was chair of the Department of Medicine at Cooper University Health Care for more than 20 years and now is the founding director of the Center for Humanism at Cooper Medical School of Rowan University.

  Dr. Viner has become a mentor to both of us. In fact, he helped plant the seed in our minds that we ought to study the effects of compassion in a scientifically rigorous way and make sure it is taught to medical students and physicians—to “science this up.” He is one of the reasons this book came to be.

  Dr. Viner found, through firsthand experience, that compassion for patients affects their physiology. Compassion can literally help patients have the strength to breathe, as it did for him.

  But, equally important, the nurses’ compassion also affected him profoundly in his mind. It gave him the belief that he could, in fact, recover. And this leads us to a discussion of our next topic: the psychological health effects of compassion.

  CHAPTER 4:

  The Psychological Health Benefits of Compassion

  “Our sorrows and wounds are healed only when we touch them with compassion.”

  —Buddha

  Psychiatrist Dr. Helen Riess is the director of the Empathy and Relational Science Program at Massachusetts General Hospital and a professor at Harvard Medical School. In brief, her research is focused on the science of human connection.

  In her TED Talk, entitled “The Power of Empathy”, she explains that one of her most fascinating scientific discoveries was propelled by an observation that she made, of all places, on an airplane.146 She was just settling in for a long flight from Boston, bound for the west coast. The cabin was completely quiet as the plane ascended to cruising altitude, when suddenly a piercing sound broke the silence…the shriek of a baby crying hysterically!

  We have all been on that fligh
t before. People respond differently: some passengers try to move to another seat, some get visibly annoyed and agitated, and some brave passengers take an entirely different approach.

  Understanding how stressful it must be for the parent who is struggling to console the crying baby, these passengers offer words of support to the mom or dad. Many even do so loud enough—intentionally—so that anyone sitting nearby is encouraged to be compassionate as well.

  But a passenger response that Dr. Riess witnessed on this particular flight was not only amazing but totally unexpected. As the inconsolable baby ramped up his ear-splitting cries to echo throughout the cabin, a little boy who was barely three years old wiggled out of his seat, toddled over to the screaming baby, and offered him his own pacifier!

  “Wow,” thought Dr. Riess, “that little boy really heard and felt that baby’s distress.” And then that little boy decided to do something about it. That’s the essence of compassion.146 But what happens, scientifically, when two human beings connect in that kind of moment?

  Compassion Relieves Psychological Pain

  In Chapter 3, you learned about the effect that compassionate care can have on the autonomic nervous system. Research shows that the giver of compassion can activate the parasympathetic nervous system (for a calming effect) in the receiver of compassion, and even that their brain waves can begin to “mirror” each other.102, 103, 104, 115 But the work by Riess and her colleagues takes this concept one step further, through the use of psychotherapy.147