Compassionomics
Page 17
The researchers recorded the audio of visits with the pediatricians, and then two weeks later they held follow-up interviews with the parents to determine if they were following the pediatrician’s treatment advice. Where applicable, the researchers performed “bottle checks” to see how much medication was left in the bottle at the time of the interview, to objectively test whether or not they were truly taking the medicine.
What they found was that a lack of “warmth” in the communication from the physician (as assessed by the parent) was associated with significantly lower adherence to the pediatrician’s treatment recommendations. Actually, the proportion of patients with optimal adherence was 15 percent lower when the parent believed that warmth was absent, compared to when they believed it was present.
And when parents had the highest level of dissatisfaction with the warmth of the pediatrician (i.e., the worst doctor-patient interaction) adherence was the worst. Only 17 percent of patients in this category were following treatment recommendations closely!
In another study of 22 physicians and 370 of their patients in primary care, researchers measured the strength of the doctor-patient relationship using a validated scale of the patients’ assessment of concordance (i.e., being “on the same page” as the physician).216 They found that strong doctor-patient concordance was independently associated with 34 percent higher odds of patient adherence to prescribed medications.
Another primary care study of patients with high blood pressure measured physician compassion (as rated by patients) and found that lower compassion from physicians was associated with significantly lower adherence to blood pressure medication.217
Similarly, a NIH-supported study from the University of California San Francisco published in JAMA Internal Medicine studied 9,377 patients with diabetes and found significantly higher adherence to medications with better interpersonal connection, specifically when patients had more trust in the health care provider.139 Perhaps this explains, at least to some extent, why (as you saw in Chapter 3) research has found that health care provider compassion is associated with better blood glucose control and fewer complications requiring hospitalization among patients with diabetes!136, 137
You will also recall from Chapter 4 that there was a NIH-supported study from the University of Colorado in which they studied the effect of compassionate language from the clinician in the treatment of patients with depression.171 That’s the one where compassionate language was found to be not only an independent predictor of adherence to antidepressant medications but also whether or not the patient even went to the pharmacy to get the prescription filled in the first place. This better self-care may explain, at least to some extent, the overall results described throughout Chapter 4, where compassion for patients with depression was associated with alleviation of depression symptoms.166, 167
So does this phenomenon only exist with primary care or mental health providers and their patients? Not according to the data.
The association between health care provider compassion and better patient adherence is also evident in the treatment of cancer. In a 2007 study from University of California Los Angeles, supported by a grant from the American Society of Clinical Oncology, researchers studied 881 women who had breast cancer and were undergoing chemotherapy with a drug called tamoxifen.218
In certain patients, the use of tamoxifen could reduce the risk of cancer relapse and death; however, it often requires a very long course of therapy (e.g., up to five years) to be maximally effective. Of course, it can be extremely challenging to adhere to such a long course of treatment. But if patients do not adhere to the chemotherapy, a relapse of cancer may be more likely.
In this study, researchers tested the association between emotional support from their health care providers over time (as rated by the patients, using a validated survey) and the patients’ adherence to tamoxifen therapy. In the analysis, they accounted for many potential confounding factors, including tumor characteristics, cancer staging, other cancer treatments received, and any side effects that they experienced from tamoxifen, so we can have confidence in the results.
What they found is that four years after the cancer diagnosis, patients who perceived receiving “the right amount” of emotional support from their health care providers had significantly higher adherence to tamoxifen, compared to patients who reported “less than needed” emotional support from health care providers. In fact, the proportion of patients still adhering to therapy was 12 percent higher (81 percent, versus 69 percent) in the patients who reported receiving enough support from health care providers, compared to not enough support.
Here’s another one: Take a moment to recall the neurology study from Chapter 3, in which physician compassion was associated with less pain and disability among patients with migraine headaches.125 Taking a deeper dive into that study, we can identify another potential mechanism of action for the pain relief that the patients experienced.
The researchers found that the compassion of the neurologist was associated with better patient adherence to prescribed therapy, both adherence to behavior modification and adherence to prescribed pharmacological therapy. So connecting the dots: more compassion leads to better adherence to the treatment plan, which delivers more relief from symptoms. Makes sense, right?
But self-care is not just about taking medicines and behavior modification. It’s also about disease prevention, like following through on recommendations for cancer screening, for example. In a study of 1,205 women conducted at Georgetown University and funded by the National Cancer Institute, researchers found that a stronger relationship with primary care providers (as rated by patients) was associated with better patient adherence to primary care providers’ recommendations for cancer screening.219
Compared to patients of low compassion providers, the rate of cancer screening adherence among patients of high compassion providers was 13 to 30 percent higher.
Specifically, patients’ assessment of the providers’ compassion was associated with patients following through on cancer screening. Compared to patients of low compassion providers, the rate of cancer screening adherence (i.e., cervical cancer, breast cancer, and colon cancer) among patients of high compassion providers was, relatively speaking, 13 to 30 percent higher.
Benjamin Franklin is credited with the famous saying: “An ounce of prevention is worth a pound of cure.” These data on cancer prevention, coupled with the data for adherence to therapy that can stave off disease progression and complications, are scientific evidence that compassion for patients is not just a powerful therapy for treating serious disease, but also can be a meaningful intervention to keep patients free of disease in the first place.
Connecting to Purpose
“Those who have a ‘why’ to live, can bear with almost any ‘how.’”
—Viktor Frankl
Think back to the story of Harry and the dreaded hat. Dr. Angelo really knew Harry as a person, and what was the result? He understood Harry’s purpose…why Harry continued to get out of bed in the morning and fight for better health, despite his terminal diagnosis.
Harry’s purpose in life was his family: being there for the kids’ recitals and ball games and, ultimately, for one more Thanksgiving. That is what drove him. Ultimately, it was that purpose (and his trust in Dr. Angelo) that made Harry agree to be admitted to the hospital. Getting his pain under control was not Harry’s purpose; that was just a goal. The real purpose was spending one more Thanksgiving at home.
It may be intuitive to you that a sense of purpose in life can be a powerful thing. In the concentration camps of World War II, Austrian psychiatrist and Holocaust survivor Viktor Frankl found that having a deep sense of meaning in one’s life was a distinguishing factor of resiliency that allowed people to survive the atrocity.220
But now, emerging research in the biomedical literature is showing how powerful having a purpose in life can be for achieving better health. Researchers define purpose in life as a sel
f-organizing aim of one’s life that stimulates goals, manages behavior, and provides a sense of meaning.221, 222 There are well-validated survey instruments in clinical studies that assess patients’ degree of purpose in life.
Purpose in life is a strong motivator for patient self-care. If patients have a clear idea of who or what they are trying to get better for (or stay healthy for), then they have a purpose in life. Rigorous research shows that when patients know what they want to live for, they experience better health outcomes.
Purpose in life was associated with significantly higher odds of adhering to health screening recommendations.
One study from the University of Michigan tested the association between purpose in life and the use of preventive health care services in more than 7,000 patients age fifty and older.228 Their conclusion: Purpose in life was associated with significantly higher odds of adhering to health screening recommendations, including cholesterol screening, colonoscopy, mammography and cervical cancer screening among females, and prostate examination among males. Furthermore, they found that purpose in life was associated with significantly fewer nights spent as an inpatient in a hospital.
In large population-based studies, other researchers have found that purpose in life is a strong predictor of mortality—it lowers mortality risk—across adulthood.223 These results on longevity have also been corroborated by researchers from the Icahn School of Medicine at Mount Sinai in New York, who found that purpose in life was associated with fewer cardiovascular events.221 And when it comes to older adults, rigorous research has found that having purpose in life is associated with fewer heart attacks and strokes.224, 225
A Harvard T.H. Chan School of Public Health study of 1,461 elderly patients found that having purpose in life was associated with better functional status and, specifically, a 14 percent lower risk of developing a slow walking speed in old age.226 Literally, without purpose in life, people lose the “pep in their step”.
People with purpose in life even sleep better at night. Research shows that purpose in life is associated with lower incidence of developing sleep disturbances.227
Science shows that purpose matters. Purpose is powerful.
So why are we telling you about the data for purpose in life in a book that is dedicated to the science of compassion? It’s simple.
If health care providers do not care enough to find out a patient’s purpose in life, they may never know what it is. And if they don’t know what a patient’s purpose in life is, they may be less effective in helping their patients connect to and fulfill their purpose. If health care providers do not know what their patients’ purpose in life is, they may not understand what health goals their patients actually value.
Also, if patients do not have a clear sense of purpose in their life, or they have not yet found what it is, this can be a major risk factor for adverse long-term health outcomes. 221, 223, 224, 225, 228 So if health care providers do not care about their patients’ purpose in life, they may never find out that their patients’ lives lack that purpose. And if they do not care enough to ask, they certainly won’t care enough to help their patients find purpose.
Here’s where compassion comes in: compassion for patients makes health care providers more likely to connect in a more meaningful way, truly understand what their patients’ purpose in life is, and—by extension—relate that purpose in life to establishing health goals with their patients.
At Cooper University Health Care, two very special primary care physicians have experienced firsthand the power that purpose in life can have in achieving health outcomes among the most challenging patients. Drs. Alexandra Lane and Jennifer Abraczinskas are physicians who practice in the Ambulatory Intensive Care Unit (ICU) at Cooper. This is a primary care clinic specializing in the care of patients with the most complex chronic care needs.
In the medical literature, the patients seen in the Ambulatory ICU are sometimes called “high-need patients”, “high need, high cost patients”, or “super-utilizers”.229, 230, 231 Sometimes health care providers even refer to them as “frequent fliers”, because of the frequency with which they are admitted to the hospital.
You may be aware that in the U.S. a small fraction (~5 percent) of all patients have especially complex chronic care needs to such a degree that they account for around 50 percent of all health care spending.232 This small segment of the total population is one of the highest priority challenges from a public health perspective.
These are precisely the patients that Drs. Lane and Abraczinskas specialize in. Due to severe chronic health conditions, these patients are extremely sick on any given day, always teetering on the edge of needing to be admitted to the hospital. Importantly, these patients typically also have very complex socioeconomic factors that complicate their health care, the most common of which are poverty and a lack of reliable support systems to assist with their care.
Some of them also have concurrent mental health conditions which further complicate their overall care. Treating these patients’ severe chronic illnesses is extremely challenging, but when you add poverty, a lack of family support, and other complex factors, it becomes infinitely harder.
Nevertheless, Drs. Lane and Abraczinskas have been extremely effective in keeping their patients well (or at least well enough to stay out of the hospital). Caring for patients with the greatest, most complex needs has become a calling for them both, and it has given them a great sense of purpose.
They are deeply passionate about what they do, as evidenced by their amazing results: better health, better quality of life, and lower health care resource utilization (i.e., fewer hospital admissions and lower costs) among patients in the Ambulatory ICU.
But how? What is their secret?
There are many intricate aspects of their practice that contribute to their patients’ successful achievement of health goals, but one factor stands out from the rest…purpose in life!
Drs. Lane and Abraczinskas care deeply about their patients. Their patients are very special, for all the reasons mentioned above, and they treat them accordingly. Lane and Abraczinskas are both known for their compassion for patients, and this is vitally important given the very extreme health and socioeconomic problems their patients are facing every day.
As a result of this compassion, and because they understand the scientific data on the significance of purpose in life, they connect with their patients in a special way. In their experience, they have observed that the high needs patients that are most likely to improve are those who have a clear sense of purpose in their lives and who are able to align their health goals with their purpose in life.
As a result, they make certain to understand their patients’ purpose in life, and then connect to that purpose. They make certain to align the explicit goals of care with what their patients’ value the most. Their results are truly remarkable, not only at the population level but also at the personal level.
Take Rasheed, for example.
Rasheed’s Story
Rasheed was only 44 years old, but his admissions to the hospital were literally too numerous to count…totally off the charts. He typically spent multiple days per month admitted to the hospital.
Rasheed had severe high blood pressure, which would have been very difficult to control even if he had no socioeconomic challenges. But he was also living in extreme poverty. He had no family to speak of. He also suffered from crippling anxiety.
Much of this anxiety was the result of being repeatedly exposed to violence in his life and being the victim of violence himself. Complicating these matters was a long history of substance abuse. His drug dependence was a byproduct of trying to self-medicate his anxiety disorder for many years (due to a lack of consistent follow-up with mental health services).
Further complicating all of the above was a concurrent eye condition requiring him to wear dark sunglasses all the time, even indoors. As a result, many people considered him to be odd or even strange, which only increased his
social isolation and compounded his anxiety. Rasheed had been unable to adhere to the eye doctor’s recommendations in the past, so he was not considered to be a candidate for corrective surgery.
All of the factors above also resulted in poor adherence to his blood pressure medication. He also didn’t adhere to his physician’s recommendations for lifestyle modification to control his blood pressure.
For years, Rasheed’s blood pressure was so out of control that he was frequently admitted to the hospital because of the stress it put on his heart, causing fluid to build up in his lungs or causing him severe chest pain. As a result, he developed congestive heart failure. Sometimes, his out of control blood pressure was so severe that it would even cause him to have neurological symptoms (“mini-strokes”).
If something did not change soon, Rasheed was going to die.
But then Rasheed was referred to Drs. Lane and Abraczinskas in the Ambulatory ICU at Cooper. They did not see him as a super-utilizer; they saw him as a person. Yes, he was among the most complex of the complex patients, and the most challenging of the challenging. But they cared deeply about him and got to know him as a person, a person that was in need of their compassion. So they set to work exploring the root causes of his years of uncontrolled disease and substance abuse, and they sought to understand Rasheed’s purpose in life.