Compassionomics

  Why is this important for compassion? A personal connection is integral to compassion. With depersonalization, there can be no compassion. It’s not possible to have compassion for another person if there is an inability to see others’ humanity on a personal level.

  Depersonalization prevents compassion.

  Therefore, the presence of depersonalization among health care providers is a marker for an inability to have compassion and an absence of compassion. Although depersonalization and compassion are not opposites, depersonalization prevents compassion.

  Accordingly, by examining the association between depersonalization and patient safety metrics, we can gain valuable insights on how a lack of compassion can affect the system of care and—by extension—patients.

  Do No Harm: A Lack of Compassion Can Pose a Safety Risk to Patients

  Let there be no mistake: As noted earlier, the main determinant of a good clinical outcome is clinical excellence. That is, the technical quality of care. No amount of compassion can make up for poor quality of care. All the compassion in the world won’t make up for getting a diagnosis wrong, prescribing the incorrect medication, or botching a surgical procedure.

  That said, a lack of compassion can predispose health care providers to giving suboptimal care. A patient’s risk of harm can actually be higher in the absence of compassion. To be clear, a health care provider who doesn’t demonstrate compassion didn’t just miss an opportunity to improve an outcome for his patient, but he or she is also more likely to harm a patient—to remove the chance for an acceptable outcome through this omission. And that’s important.

  There is tremendous focus in the health care industry on ensuring that preventable harms (i.e., medical mistakes) do not happen to patients. Actually, the U.S. government’s Department of Health and Human Services’ Center for Medicare and Medicaid Services (CMS) adjusts payments to hospitals based on harms to patients and rewards those hospitals with the fewest errors. And yet, there is just such a risk when compassion is absent during care.

  Let’s take a look at the data: The key linkage is the data on depersonalization among health care providers and quality of care provided. Earlier, you read that with depersonalization—that inability to make a personal connection—compassion for patients is impossible.

  Of course, compassion is absent where there is no human connection. Without this connection, health care providers may not be as meticulous about the technical quality of care as they could be. There is robust evidence in the scientific literature that depersonalization represents a risk of harm to patients.

  For example, in 2009 researchers from the Mayo Clinic published a longitudinal study in JAMA in which they studied 380 internal medicine resident physicians and tested the association between their scores for depersonalization and emotional exhaustion and the incidence of major medical errors committed by the physicians.236

  In addition to depersonalization being an important marker for an absence of compassion, so is emotional exhaustion, because it can be an indicator of compassion fatigue among health care providers. In fact, it’s probably intuitive that depersonalization plus emotional exhaustion is virtually guaranteed to result in compassion fatigue, at least to some degree.

  In the study, residents were surveyed every three months for the duration of their three-year training program. The survey captured the physicians’ self-reported major medical errors—only those medical errors which the physicians themselves considered to have serious consequences (or potentially serious consequences). The survey was anonymous, so it is highly unlikely that the physicians were concealing major errors. Nearly 40 percent of these physicians reported committing a major medical error at some point.

  What they found was striking. Physicians who scored high for depersonalization were significantly more likely to commit a major medical error in the next three months. For any measurable increment of depersonalization on the scale (i.e., just one point higher), the odds of a major medical error were 9 percent higher. That translates to at least 45 percent higher odds of a major medical error in the next three months for the physicians scoring in the highest tier of depersonalization, compared to those who scored in the lowest tier.

  Similarly, physicians who scored high for emotional exhaustion were also significantly more likely to commit a major medical error in the following three months. The odds were 6 percent higher for any measurable increase in emotional exhaustion, which translates to at least 54 percent higher odds of a major medical error for the physicians scoring in the highest tier of emotional exhaustion, compared to those who scored in the lowest tier. Again, the outcome measure for this study was a major medical error. Would you want to take a chance with one of those physicians?

  In another study from the same Mayo Clinic researchers that was also published in JAMA, they used the same longitudinal study design surveying 184 resident physicians every three months.237 They found similar results: compared to physicians in the lowest tier for depersonalization scores, physicians that scored in the highest tier for depersonalization had at least 50 percent higher odds of a major medical error in the next three months.

  Similarly, physicians that scored the highest for emotional exhaustion had at least 63 percent higher odds of a major medical error in the next three months. But they specifically honed in on one more thing: the physicians’ compassion. They used another well-validated survey instrument that measured the physicians’ beliefs and values about their own compassion for patients.

  Physician compassion was associated with lower odds of committing a major medical error in the next three months.

  What they found was that physician compassion was significantly associated with lower odds of committing a major medical error in the next three months. How much lower? That is a little harder to answer, because there is not yet a consensus on how to define “high” and “low” levels of compassion according to the scale that they used.

  In the study above, for even the smallest measurable increment of higher compassion (i.e., just one point higher on a 28-point scale), there were 9 percent lower odds of committing a major medical error in the next three months. So, even a little bit more compassion can make a meaningful (and measurable) difference! Accordingly, it appears that compassion may actually be protective; compassionate physicians might practice in such a way that they commit fewer medical errors.

  Another study of 115 resident physicians from the University of Washington published in Annals of Internal Medicine sheds light on the relationship between depersonalization and quality standards among health care providers.238 Using an anonymous survey, the researchers tested the association between physicians’ level of depersonalization towards patients and their incidence of providing suboptimal care for patients admitted to the hospital.

  Examples of suboptimal patient care that the physicians admitted to included: discharging patients from the hospital just to reduce physician workload, not fully discussing treatment options with a patient or fully answering questions, medication errors that were not due to lack of knowledge or inexperience, ordering restraints or medication for an agitated patient without evaluating the patient, skipping a diagnostic test because of a desire to discharge a patient, paying little attention to the social or personal impact of illness on a patient, and feeling guilty from a humanitarian standpoint about the care (or lack thereof) provided to a patient. This is essentially a list of items that you would never want to occur if you or a family member were in the hospital.

  What they found was that depersonalization among the physicians was independently associated with higher incidence of self-reported substandard care at least monthly (and even weekly), which obviously is a reflection of having low quality standards. It turns out that the relationship between depersonalization and substandard care was “dose-dependent”; the higher the depersonalization score, the more likely the physicians were to provide substandard care. Compared to the physicians with the lowest scores for depersonalization, the
physicians with high depersonalization scores had more than four times higher odds of substandard patient care practices.

  If you’re a health care provider, you may have encountered colleagues that suffer from depersonalization who are unable to make personal connections or who have really stopped caring about patients. Perhaps you have also observed them cutting corners in terms of quality standards?

  The data are pretty clear that depersonalization among medical doctors is associated with increased risk of harm to patients, but what about surgeons? In a study of 7,905 surgeons across the U.S. led by researchers from the Mayo Clinic, they surveyed members of the American College of Surgeons and tested the association between depersonalization/emotional exhaustion and the occurrence of major surgical errors.239

  Again, they used validated scales to measure depersonalization and emotional exhaustion as well as the occurrence of errors by surgeons. Errors were assessed by self-report, confidentially asking the surgeons if they made any major errors in the past three months.

  They found that, overall, 9 percent of surgeons reported making a major surgical error. Both depersonalization and emotional exhaustion among surgeons were significantly associated with a higher incidence of major surgical errors. These results, stratified by levels of depersonalization and emotional exhaustion, appear in Figure 6.1.

  Figure 6.1: Proportions of surgeons (total n=7,905) reporting they made a major surgical error in the past three months, stratified by their level (i.e., from left to right: low, intermediate or high) of emotional exhaustion (EE) and depersonalization (DP).

  Source Annals of Surgery

  (Shanafelt, Balch et al. 2010)

  It’s a dramatic difference, isn’t it? Compared to surgeons with low depersonalization or emotional exhaustion scores, surgeons with the most severe depersonalization and emotional exhaustion had a sharply higher error rate. The proportion of surgeons who committed a major error in the past three months was three times higher! The number one contributing factor in making the errors? According to the surgeons, it was a lapse in their clinical judgment.

  In summary, surgeons scoring very high in depersonalization (which involves objectifying patients as well as being uncaring and callous towards them) and surgeons scoring high in emotional exhaustion (which leads to compassion fatigue) are prone to a lapse in clinical judgment that can result in a major error.

  Concerning? Yes. Surprising? Probably not. (Here’s a thought: maybe you should ask your surgeon how he or she is feeling before you go under the knife?)

  Numerous other clinical studies have similarly supported that health care providers’ inability to build meaningful relationships with patients can lead to low quality of care and is a risk to patient safety. For example, a Swiss study of 1,425 nurses and physicians working in ICUs found that emotional exhaustion—a precursor to compassion fatigue—among ICU staff was associated with higher ICU mortality.240 So it’s not just a higher error rate…it’s a higher death rate.

  A lack of compassion among health care providers can be a serious patient safety risk.

  An anonymous survey study of 681 emergency physicians in the U.K. found that compassion fatigue among emergency physicians was also associated with reducing their quality standards in the emergency department in a way that could harm patients.241 In fact, one-third of physicians with compassion fatigue reported these behaviors at least monthly. Taking all of the available data together, the evidence is clear. A lack of compassion among health care providers can be a serious patient safety risk.

  What Compassion Fatigue Looks Like in Practice

  Recently, a cardiologist shared an experience about a favorite patient of hers, Gina, an elderly woman who came to an appointment very anxious about an imminent surgical procedure that she needed. Normally, Gina was very energetic and outspoken. She was full of life.

  But at this appointment, Gina was a wreck. Her family explained that she wasn’t sleeping at night—she had not had a good night sleep in weeks, actually—because she was so worried she might not survive the surgery. They asked the cardiologist if she could possibly prescribe a medication to help her sleep.

  Normally, a cardiologist doesn’t prescribe these sorts of medications. When needed, they are usually handled by the patient’s primary care physician (PCP). But when the cardiologist looked through Gina’s electronic medical record, she noted that Gina had already communicated with her PCP about it.

  She saw notes about telephone communications between that PCP and his staff in the office. Essentially, that doctor blew off the request. He instructed his staff, “If surgery is the reason why she can’t sleep, tell her to ask the surgeon to prescribe it.”

  Why couldn’t he help his patient?

  The cardiologist made the diagnosis just from reading the notes in the computer. The PCP was burned out. It was obvious. His failure to appropriately care about his patient’s well-being was depersonalization in action. Gina’s PCP wasn’t thinking about her as a person…a person who was in need of his help. To the PCP, Gina was just one more task to get through in an overflowing inbox of tasks at the end of a long day. It was easier to just “pass the buck.”

  The cardiologist cared deeply about Gina, and of course she helped her. Not just with a sleep aid, but she also treated Gina with compassion. She took the time to talk with Gina, to find out why she was so afraid of surgery and why she thought she was not going to survive it.

  She reassured Gina and helped her to understand that she was not going to die. She told her that she would not go through this experience alone. And, just as we saw the scientific evidence for the power of compassion in the treatment of anxiety (Chapter 4), that compassionate connection with her cardiologist made all the difference for Gina. It made her much less anxious, helped to quell her fears, and helped her get through the surgery with peace of mind.

  Emotional Harms: Invisible but Real

  So far in this chapter, we have examined how a lack of compassion can reduce the quality of care leading to physical harms, such as major medical or surgical errors or other adverse outcomes. But are those really the only outcomes that matter? What about the harms to patients that do not leave a mark on the outside, but rather leave a mark on the inside?

  Recently, The New England Journal of Medicine asked health care providers to imagine scenarios such as these:242

  • A patient with a recent diagnosis of cancer goes to the emergency department, due to a complication of chemotherapy. The emergency department physician reads through his medical records from the oncology clinic and says bluntly, very matter-of-fact, “Since your cancer is incurable…” Wait, incurable? The patient’s oncologist had not yet used those words with him. This is the first time the patient has heard this.

  • A physician has to notify her patient about test results. They’re not good. The physician has to give her the bad news. No one thought to ask the patient ahead of time how she wants to receive the information or who she wants to be around for support when she receives it. The phone call from the physician comes when she is away from home. All alone. And she is driving sixty-five miles an hour on the interstate.

  • A morbidly obese woman is admitted to the hospital. Speaking to a colleague, a resident physician makes a judgmental, derogatory statement about her obesity after he steps outside the patient’s room. What the resident physician does not realize is that the patient is still within earshot. She heard everything and is humiliated. It’s not the first time in her life she has been humiliated by someone because of her weight, but this time it’s different. It’s her doctor.

  • A son receives a 3 a.m. phone call from an ICU resident physician asking for his consent to do an emergency procedure on his elderly father. “Wait, ICU?” he asks. “My father is not in the ICU.” But actually, he is. He’s dying. Hours earlier on the cardiology floor, the patient suddenly and unexpectedly went into cardiac arrest and, with all the various caregivers’ efforts to keep him alive, no one remembered to call h
is family.

  • A woman comes to the emergency department because of abdominal pain and, ultimately, she needs to be evaluated by a specialist. Unannounced, the consulting physician barges into the patient’s room while she is sitting on the bedpan. Clearly in a hurry, after barely explaining who he was or why he was there, the physician does exactly what he came to do: he begins to examine the patient’s abdomen.

  Without asking permission or any forewarning, the physician lifts up the patient’s gown, but does not pull the bedsheet up to maintain her privacy. The physician does not even remember to close the curtain around her bed. Family members from the next room over can see her. She is mortified—totally exposed.

  • A patient complains on a hospital’s Facebook page that the pre-operative paperwork for his surgery instructs him to check in at 5 a.m. He makes sure he’s up by 3:30 a.m. because he has over an hour drive to get to the hospital, only to arrive and learn that patients can’t actually check in until 6 a.m. When he expresses frustration, the staff tells him, “The 5 a.m. thing is a little ‘trick’ we use to make sure patients don’t arrive late.” The whole experience makes him wonder what other little “tricks or surprises” they might have in store for him during his surgery later that morning.241

  These are all true stories…very real emotional harms that occur in hospitals and other types of health care facilities daily. In the constant quest to keep to a schedule and deliver quality clinical care, health care providers frequently overlook things like these that they don’t deem important.