Compassionomics

by Stephen Trzeciak

  Over months of regular check-ups in the Ambulatory ICU, Drs. Lane and Abraczinskas came to a striking (and sad) discovery. Rasheed had no sense of purpose in his life. They suspected that his lack of purpose in life was a major factor in his years of very poor health.

  But how do you help someone find purpose in life when they have none?

  Drs. Lane and Abraczinskas were aware of some very powerful data. That is, the data on living an “other-focused” life, a life that is focused on service to others. There is a robust body of scientific evidence that serving others can actually be beneficial for one’s own health and well-being.

  Could this result in meaningful change for Rasheed?

  In Rasheed’s local community, there were many people that were suffering from high complexity health challenges, just like Rasheed himself was experiencing, and many of them had diseases that were just as severe and uncontrolled. After gaining Rasheed’s trust over time, and seeing small but meaningful improvements in his health, Drs. Lane and Abraczinskas encouraged Rasheed to get involved in his community, helping others around him to get control of their own health. They encouraged him to serve.

  Feeling like he was at the end of his rope, and having essentially nothing to lose, Rasheed trusted his doctors and took their advice. This new beginning proved to be nothing short of miraculous for him.

  First, Rasheed knew that the only way that he could be a credible inspiration for others was to take ownership of his own health. For the first time, he completely stopped using drugs. He went “cold turkey.”

  For the first time, he was strictly adhering to his prescribed medication regimen. He never missed a dose. For the first time, he kept all of his appointments with mental health providers. Rasheed became a model patient. He was finally able to have the eye surgery that he needed, so that he no longer needed to wear dark glasses all the time. He was a new person!

  Rasheed became a health coach in his community. He even made a new career out of it, working part-time as a health coach in a local clinic. He loved helping others get control of their health. He found it so rewarding.

  This motivated Rasheed to take the best possible care of himself. This, in turn, allowed him to be a shining example for all those around him in his community who were struggling with high complexity health conditions. It was a “virtuous” cycle.

  Serving others, and helping others get control of their complex health conditions, became Rasheed’s newfound purpose in life.

  Drs. Lane and Abraczinskas helped Rasheed connect to that purpose by working diligently to help keep his health in check and by seeing him in the Ambulatory ICU clinic at a moment’s notice if he needed any kind of attention. They understood it was vital to keep his health in the best possible condition, so that he could be an effective role model and available to serve others.

  Since rededicating his life to serving others as a health coach, Rasheed has not been admitted overnight to the hospital. Not one time. His health—and his whole life—have made a complete “180.”

  Rasheed knows what it is like to struggle with complex health challenges, and because of this he has great compassion for others who are struggling with the same. This compassion is what drives him.

  Rasheed sees his work in service to others as a way of paying it forward. That is, paying forward the great compassion shown to him by his physicians, Drs. Lane and Abraczinskas, who were the people who cared enough about him to help him find (and connect to) his new purpose in life!

  CHAPTER 6:

  Compassion is Vital for Health Care Quality

  “(Compassion is)…one of the impulses that nature has implanted in us to do what our duty alone may not accomplish.”

  —Immanuel Kant

  So far, we’ve examined the scientific evidence for a direct impact of compassion on patients physiologically, psychologically, and for their self-care. But what about its impact on the technical quality of care?

  The effects of compassion on the health care environment and the system of care have a downstream effect on patients in meaningful ways. So in this chapter we will consider the effect of compassion on health care itself and the processes of care.

  How Compassion Affects Quality

  The National Academy of Medicine (formerly called the Institute of Medicine) defines health care quality as: “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”233

  This includes the use (or misuse) of health care resources—something you’ll read more about in the next chapter, during our discussion about the effects of compassion on health care costs. But for the moment, let’s hone in on just the effects on the clinical processes of caring for patients (i.e., clinical quality).

  You will recall that embedded in the overarching hypothesis that compassion benefits patients is an additional hypothesis: compassion improves the quality of patient care and processes of care. There are two different signals in the data that could support this.

  The first is any data showing that low compassion—or absence of compassion—is associated with worse quality of care. The second is any data showing that more compassion is associated with better quality of care. Collectively, either type of data would support the hypothesis that compassion is beneficial for health care quality.

  In reality, our systematic review did identify compelling data about the latter (high compassion and higher quality) but found a lot more data on the former (low compassion and lower quality).

  Why? It’s largely because of the way in which hospitals and health systems measure the technical quality of care. Quality metrics are often based on rates of complications of care, such as medical errors. Rather than focusing on the vast majority of events that go exactly as planned, they are often focused on the small numbers of cases that go wrong.

  The nature of quality metrics is often about tracking the bad things that can happen to patients. That’s because the goal for hospitals and health systems is to have the incidence of bad things be as low as possible. That’s mostly good news: hospitals and health systems should expect things to go well for patients and be interested in measuring and, therefore, preventing problems.

  So, in tracking these bad outcomes or medical errors, the data to support the hypothesis that compassion benefits clinical quality would be data supporting that low compassion is associated with higher incidence of things going wrong. In other words, it would support the idea that low compassion makes patients less safe.

  Why would that happen? One possibility is carelessness. Health care providers that don’t really care about their patients may be more careless in the technical aspects of medical practice. On the flip side is meticulousness. Health care providers that care deeply about patients also may be more meticulous about the technical aspects of the medical care they provide.

  For example, if health care providers care more, they may pay more attention to detail to make sure that nothing goes wrong (or that everything goes perfectly). They also may be more willing to go the extra mile for patients to help ensure the best possible medical care—not just acceptable care, but exceptional care.234, 235 (But, as stated earlier, that’s a harder signal to pick up in the health care quality data because it is commonly focused on the occurrence of adverse events.)

  Now that you understand why there is a preponderance of this kind of data, let’s examine this link between a lack of compassion and poor quality of care. Later, we’ll consider the other possibility: how more compassion could increase health care quality.

  A Lack of Compassion is a Threat to Patient Safety

  Here’s a rather dramatic, yet true, story that illustrates this point:

  A 75-year-old woman is heroically saved at a major trauma center, only to be discharged and fatally struck by a car on her way home from the hospital. Could a lack of compassion from the hospital staff have contributed to her death?

  Yes. Here’s h
ow it happened:

  It seemed like any other morning to the resident physician, walking in to the hospital at 7 a.m. to begin a 24-hour shift as part of the trauma team. But when she arrived in the emergency department, it was clearly not a normal morning. It was downright eerie.

  As the resident physician walked into a trauma resuscitation bay, there was blood everywhere, and an elderly female patient lying on the gurney had just been pronounced dead. This aspect of the morning, unfortunately, was not so unusual.

  But what was odd was how the entire trauma bay was almost silent. Instead of the usual buzz of activity at the change of shift, the whole staff was very somber, despondent. They were whispering to each other and appeared crestfallen. They had pronounced patients dead on numerous occasions. But something was different this time.

  Even worse was the expression on the face of a nurse holding the phone to her ear as the resident walked past. The nurse appeared to be in anguish and looked like she was going to pass out.

  What was going on?

  A colleague explained: The 75-year-old woman (we’ll call her Mrs. Johnson) had actually arrived the night before, after falling down a flight of stairs at her home just a couple blocks away. She was rushed to the emergency department by ambulance and, after initial evaluation by the emergency medicine team, the trauma team was called to evaluate her.

  Soon after her arrival at the hospital, her entire family arrived…about twenty people in total! Clearly, Mrs. Johnson was the matriarch of the family and everyone was really concerned.

  Fortunately, the family received good news early on: she was alert and talking, and all of her testing, including a computed tomography (CT) scan, came back as showing no evidence of serious injury. So that was reassuring.

  But Mrs. Johnson still complained of one thing: hip pain. Although there was no evidence of an obvious fracture on the initial set of imaging, the trauma team was concerned there could be a small hip fracture that the standard imaging was not picking up. So they ordered more tests. All the really serious injuries were already ruled out, but they needed to do more imaging of the hip, just to be sure.

  Now it was already really late—the wee hours of the morning—by that time. The radiology department was backed up with other patients with more urgent, potentially life-threatening, conditions. It could be a couple more hours of waiting until everything was done, so the trauma team told the family they could go home.

  Given her significant hip pain, all the health care providers assumed that they would find a small fracture and that she would be admitted to the hospital. The family agreed to go home and come back in the morning after getting some rest. But when all the testing and interpretation was finally complete, it was negative. All of it. Somehow, Mrs. Johnson had fallen down a flight of stairs but actually did not suffer any serious injuries, except bumps and bruises. The staff explained to her that she did not need to be admitted to the hospital and could go home.

  By that time the sun was just coming up and, knowing her family had been awake most of the night with her in the emergency department, Mrs. Johnson was hesitant to wake her family to ask for a ride home. And then, when she finally did phone home, no one answered because they were all sleeping.

  She explained to the staff that, even though her hip was still hurting, she thought she could make it home on her own. She lived just two blocks away from the hospital. It was a short walk.

  But here’s one question the staff did not ask: “In which direction?” On one side of the hospital was a residential community. On the other side of the hospital was a very busy four-lane road, one of the major arteries of the city, with a speed limit of forty miles per hour. It was true that her house was only two blocks away from the hospital, but it required crossing that very busy road.

  Here’s another question the staff did not ask: “Is there anyone else I can call for you to come and get you—a friend, maybe?” And yet another: “May I see you walk before you go, just to make sure you are steady on your feet and okay to walk?”

  How about one more question that nobody asked: “I’m sure you’re awfully tired. How about we discharge you and you can take a seat in the waiting room until your family wakes up and can drive you home?”

  But since nobody asked any of those questions, Mrs. Johnson left on her own. She was hobbling very slowly. As soon as she stepped off the sidewalk to cross the street in front of the hospital, she was blindsided by a speeding car. This patient—just discharged—who was concerned about further troubling her family, was then admitted (for the second time in eight hours) into the very same emergency department she just left.

  You already know the outcome. She died. In fact, her injuries were so severe from being struck by the car that it was obvious to the trauma team almost immediately on arrival that her injuries were not survivable. There were no signs of life. She was gone.

  What about the nurse with the phone to her ear looking like she was going to pass out? The trauma team had just pronounced the elderly woman dead when that nurse’s phone rang. It was Mrs. Johnson’s daughter. She had just heard the voicemail from her mom saying she was going to be discharged home.

  The daughter asked, “Can I come pick her up now?” The nurse was unable to speak. What an incredible tragedy.

  So what was the lack of compassion here? This emergency department staff and trauma team provided sound clinical care when she was with them. It was impeccable, actually. She had all the appropriate tests and treatment. The team “checked all the boxes” as far as the medicine was concerned.

  But they neglected to think of their patient as a whole person…to take the extra step of caring about how she would get home when the family wasn’t available to pick her up. After all, she still had hip pain, and clearly (as evidenced by the outcome) it impaired her walking.

  A little bit more care and consideration could have made all the difference for this patient. It could have saved her life. But instead, there was a fatal outcome that undid all the quality clinical care they provided earlier.

  Imagine what it felt like to have to tell her family what happened to her. Imagine what it felt like for her family to hear what happened.

  Days after the tragic incident, the physician who discharged the patient confided in the physician who was just coming on duty. He was despondent and devastated, feeling the burden of being the last person Mrs. Johnson spoke to before she died. He felt responsible.

  “When I saw that all the testing came back negative, I moved on in my mind to the next case in the waiting room,” he said. “She needed more help than just telling her the test results and handing her the discharge papers. I treated her as a ‘hip pain’, not as a person. The ‘hip pain’ did not need a ride home…but Mrs. Johnson did.”

  Making a Personal Connection Is Critical

  Earlier, you learned about depersonalization. That’s an inability to make a personal connection. Research on depersonalization comes from the studies on burnout in the helping professions, including health care providers. As described in our discussion of the compassion crisis in Chapter 1, depersonalization is one of the three components of burnout. (The other two are emotional exhaustion and the feeling that you can’t really make a difference.)

  In studying burnout, researchers use well-validated scales that measure all three components of the burnout syndrome. The questions about the depersonalization component of burnout hone in on one’s ability (or inability) to make personal connections with others. For health care providers, that means personal connections with patients. Accordingly, burnout research in health care providers can specifically report on the degree of depersonalization among providers assessed for burnout.

  Depersonalization occurs when health care providers don’t really care about patients, think of patients as objects or have become callous or hardened to patients’ needs.

  In the most commonly used research instrument for assessing burnout in health care providers, the Maslach Burnout Inventory, the measur
ement of depersonalization assesses whether or not a health care provider really cares about patients, ever thinks of patients as objects (versus knowing them as a person), or has become callous or hardened to patients’ needs. By the way, because such surveys are always confidential in the research studies described below, we can be confident that respondents feel free to be honest.

  An example of depersonalization from earlier in the book is when health care providers objectify a person’s needs, such as thinking of the patient only as “the chest pain in room six,” rather than thinking of the patient as “Mr. Hernandez in room six” and acknowledging that the patient is a person who needs help and has people who care about him.

  Depersonalization is also an inability to make a personal connection that leads to a lack of understanding of how a patient’s illness affects them as a whole person. A hand injury requiring surgery may seem non-life threatening, and therefore no big deal in the grand scheme of things, to an emergency department provider.

  But then, if they take the time to make a personal connection, they might find out that the patient is a pianist struggling to make ends meet and just lost her livelihood for the foreseeable future. Her son just got into college; how will they afford the tuition now? Maybe that’s why she’s just staring into space in the exam room, not saying much.

  Depersonalization—and the lack of a personal connection that flows from that—may also result in a lack of personal investment from the health care provider. That’s the kind of lack of caring that can lead to a lack of meticulousness and attention to detail, and lower quality standards, where adverse events are more likely to occur.