Compassionomics

  But that’s not exactly what happened when meeting with the wife of this particular patient. It was quite the opposite. When the patient’s wife of almost fifty years came to the patient’s room in the ICU, she had absolutely no idea what was in store for that meeting. She knew he was sick, but she did not yet have an understanding of how grave the situation was.

  The first error the team made was to fail to ask the wife who else in the family should be present (for multiple reasons, not the least of which is emotional support). The second error was to fail to ask her what her current understanding of the situation was, in order to predict how shocking the information may be to her.

  The third error was to fail to ask her to sit down. The wife and the ICU team were standing up next to the patient’s bed for that heavy talk. (Note: Always ask somebody to sit down before you give them the news that delivers the worst day of their life.) The fourth—and most egregious—error was a striking lack of compassion. Just like the University of Washington study: there was zero.

  In the first thirty seconds of the meeting, the physician just blurted it out in a way that was not only matter-of-fact and insensitive (like it was nothing), but also downright cold: “He is dying. He won’t survive the day. There is nothing we can do.” Full stop.

  Mind you, all of those statements were true. He was dying, and there was no way to change that. And the physician had a responsibility to communicate those facts to the wife so that she had a full understanding. It wasn’t the message. It was how the message was delivered. While a physician needs to be honest with the facts, communicating such sensitive information in such a thoughtless way is clearly an avoidable emotional harm.

  BAM! It happened so fast that no one could catch her. His wife, who was more than 70 years old herself, collapsed and hit the floor…face first. There was blood everywhere, pouring out of her nose onto the floor of the patient’s room.

  But as soon as the doctors flipped her over onto her back, they realized she did not just faint following the bad news. Something very different was happening to her. There was barely a pulse, and she was barely breathing.

  The trauma of the fall was not the primary problem; it was a catastrophic heart problem that caused her to collapse. It was a full-on resuscitation situation, but not for the patient…for his wife.

  The ICU team worked valiantly to try to revive her. When the cardiologist did an echocardiogram to look at the heart, it had the characteristic signs of Takotsubo cardiomyopathy. Sadly, she could not be saved. She and her husband both passed away within 24 hours of each other. A striking lack of compassion from a caregiver appears to be the trigger for the event that culminated in her dying from a broken heart.

  Health care providers should think of this story the next time they have to give a patient or his family bad news. A caregiver’s responsibility often extends beyond the patient.

  Compassion Elevates the Quality of Care

  Now that we have seen a myriad of ways in which a lack of compassion can lower the quality of health care, let’s look at the flip side: how having compassion for patients can lead to higher quality of care.

  There are multiple potential mechanisms by which this can occur, including:14

  • a higher level of health care provider commitment (i.e., going the extra mile)—to ensure optimal clinical outcomes;

  • higher quality standards—more diligence and meticulousness around technical quality of care—among health care providers;

  • a higher level of patient trust in health care providers, creating a better therapeutic alliance; and

  • more patient self-disclosure in medical interviews, resulting in better information gathering by health care providers and better diagnostic accuracy.

  But what is the evidence?

  In the Johns Hopkins study in HIV patients that you saw in Chapter 5, you may remember that researchers asked patients if their physician knew them as a person.201 They found that knowing the patient as a person was associated with better patient adherence to antiretroviral therapy and, accordingly, better clearance of HIV virus from the blood.

  Well, there was another finding in that study that matters here. The researchers also found that knowing the patient as a person was associated with 41 percent higher odds that the antiretroviral medication regimen prescribed by the physician matched up with experts’ best practice recommendations for treating HIV. In other words, there were 41 percent higher odds that the physician was prescribing the right medications.

  Why? This seems unlikely to be causation, right? Knowing the patient as a person probably does not cause a physician to rethink what they are prescribing. More likely, it’s correlation.

  Perhaps physicians who are the type of people who get to know their patients as a person also happen to be the type of people who make sure they are prescribing the right medications. Maybe physicians who care enough to get to know their patients as a person are also more careful in what they are prescribing.

  Or perhaps knowing the patient as a person is just a sign of competence for a physician. That is, physicians who are more competent know that building a relationship with the patient is an essential part of care.

  So, are there data on compassion and competence? Yes, multiple studies support this link, especially the assessment of competence from the patient perspective. If a patient heard a surgeon say “oops” during their operation or observed a physician Googling their disease during an office visit, the patient’s confidence in the physician obviously would take a nosedive. It’s no different with compassion.

  For example, a study of physicians in training found that compassion communicates competence.250 One way that medical schools evaluate the competence of physicians-in-training is through an objective structured clinical examination (OSCE).

  In an OSCE, an experienced independent physician evaluator (e.g., a professor in the medical school) watches a physician-in-training perform a “history and physical” on a patient and scores the physician-in-training on the competence of his or her clinical skills using a pre-defined and validated scoring system. Sometimes they videotape the OSCE and then show the video to lay people and patients who grade the physicians-in-training on their communication skills. This methodology has been shown to be a valid and reliable method of assessing the quality of physician communication in numerous studies.251

  Likewise, in a study of 57 physicians-in-training, researchers found that observed behaviors—both verbal and non-verbal—that were expressions of compassion were strongly associated with perception of clinical competence, as rated by both the physician evaluator and by patients.250 In fact, the mean score for clinical competence among high compassion individuals was 15 percent higher than it was for those with low compassion.

  In a unique study from Harvard Medical School and the Department of Psychology at Yale University, researchers tested the association between compassionate non-verbal behavior by physicians and patient perception of physicians’ clinical competence using an online crowdsourcing platform to recruit more than 1,300 people to evaluate the physicians.252 (As mentioned earlier, using lay person observers to evaluate physician communication is recognized as a sound methodology for physician communication research).251

  In this study, all of the participants read an identical passage of text that was a scripted communication from a physician to a patient. But the participants were provided different visual images to accompany the text. Some of them were shown photographs of a physician with compassionate non-verbal communication like eye-contact, being at eye level, no physical barriers, having an open posture, leaning in, and showing a concerned facial expression.

  The other participants were shown photographs of a physician with the opposite non-verbal behavior, such as no eye contact, looking down at the patient from a standing position, sitting behind a physical barrier, crossing his arms, and looking rather annoyed with their facial expressions.

  After adjusting the analyses for potential confound
ers (like the participants’ mood at the time of the evaluation), they found that participants rated physicians with compassionate non-verbal behavior as being not only more compassionate but also more competent. Similar to the prior study we just discussed, the mean competence scores for the high compassion physicians were almost 15 percent higher than the competence scores for the low compassion physicians.

  Research shows if health care providers consistently demonstrate compassion, patients are more likely to believe they know what they are doing.

  So what’s the take-home message for health care providers? If you consistently demonstrate compassionate behaviors (both verbal and non-verbal communications) for your patients, they are more likely to believe that you know what you are doing. These data support that compassion and competence—at least perception of competence—just go together, naturally. But is it just perception, or is the quality of care actually better?

  Compassion Inspires Quality Communication with Patients

  If health care providers do not care enough to find out what is worrying their patients the most, they might never know. In an interesting study from the University of Colorado School of Medicine, researchers distributed cards to patients seeking care in the emergency department asking, “What worries you the most?”253

  The patients wrote in their answers. Then the researchers compared the patients’ greatest worries to what was listed as their chief complaint on their medical chart by the emergency department triage nurse. (Chief complaint, in emergency medicine speak, is the main reason someone has come to the emergency department in the first place.)

  Here’s what they learned: Patients’ most pressing worries were often unrelated to their chief complaints. In fact, only 26 percent of people’s worries actually matched their chief complaint.254 For example, for a 68-year-old man who presented with a chief complaint of neck pain and stiffness, his greatest worry was actually, “Dying and not seeing my children and grandchildren again.”

  One 45-year-old man had a chief complaint of chest pain on his chart, but his greatest worry told a different story. He wrote, “I worry about dying too young to see my kids grow up—they’re 14, 15, and 8. I’ve got trouble with my heart because of the drugs. I don’t want to be here again, but I can’t stay away.”

  A 27-year-old pregnant female had a chief complaint of vaginal bleeding, but her greatest worry was actually depression. She wrote, “I don’t want to go into depression again. A miscarriage is hard.”

  This qualitative data shows quite clearly: if health care providers do not care enough to ask patients what their greatest worry is, they may never know. How can health care providers possibly give their patients the highest quality, patient-centered care if they do not even know their patients’ greatest worry related to their health?

  Compassion for patients not only makes a health care provider more likely to ask their patients what their greatest worry is, but it also makes them more willing to listen. Part of caring deeply about patients is letting them tell their story.

  Sir William Osler, who is one of the most famous physician scientists in the history of medicine, once said, “Listen to your patient; he is telling you the diagnosis.” Health care providers who listen intently to what patients are saying are likely to get the necessary information. Those who do not listen intently to patients are prone to errors, both in making the diagnosis and in making clinical judgments.

  And this appears to be a two-way street. When physicians have high compassion for patients, not only are they more willing to listen to patients, but patients are also more willing to listen to the physicians. Research shows that compassionate care from a physician is associated with more accurate patient recall of the medical information communicated by the physician.174, 175 This is an important part of clinical quality because it promotes adherence to treatment recommendations.

  When patients stop talking, the real trouble begins. A health care provider’s diagnostic accuracy is based largely on having all of the right information, and the completeness of information gathering is essential. Let’s face it: sometimes seeking medical care is downright embarrassing. Patients often have to share some of the most personal information imaginable. They are often reluctant to disclose information if it is of a sensitive, intensely personal nature. Patients frequently shut down and do not disclose everything fully if they think their doctor doesn’t care and doesn’t want to hear it. That’s a serious threat to patient safety.

  In Chapters 3 and 4, we reviewed data demonstrating that compassion enhances patient trust in health care providers, and that this can affect patient outcomes. But compassion also enhances patient trust in a way that facilitates patient disclosure in the medical interview. Patients don’t place their trust in physicians and nurses because of the number of diplomas they have on the wall or the reputation of the school that they graduated from. Rather, research shows that patient trust is about the relationship that they have with their providers.43

  In Chapter 5, you heard about a University of Virginia study of patients with HIV where physician compassion was associated with a patient’s belief that therapy would be effective.202 Well, they also measured patient disclosure in that study and found that patients of highly compassionate physicians disclosed more information during the visit.

  Importantly, it was not just more information that was important from a psychosocial and human connection standpoint, but also information that was important from a biomedical standpoint (i.e., relevant to the treatment of HIV disease).

  Rigorous research from Columbia University backs up this finding. Researchers found that compassion for others is a very strong predictor that another person will confide secrets in us, while mere politeness is not.205 So science shows that for others to trust us with their most closely held secrets, we need to go deeper than just common courtesy, and just having the formal role of one’s health care provider is not enough. Here too, science shows that compassion matters.

  Earlier we shared a study published in Annals of Internal Medicine, where more than three-quarters of physicians interrupted patients before they completed their opening statement of concerns.34 This is a real problem; the inability to listen attentively signals a lack of compassion and caring about the patient. That will shut down a patient quickly, making it more difficult to elicit all the necessary information for diagnosis and treatment. Here’s a more in-depth (and true) story that really illustrates the impact that compassion can have on the quality of communication, and even save a life.

  John’s Story

  It was a night shift in the emergency department of a busy academic medical center. At 1 a.m., a 45-year-old male, John, arrived complaining of a headache.

  It was clear from the moment that he arrived that John didn’t want to be there. He sat up on the gurney in the exam room of the emergency department, arms crossed, looking only slightly uncomfortable, but mostly just annoyed. He was only there because his wife made him come in. She made him come because he almost never gets headaches, and so it concerned her. He didn’t like hospitals.

  The resident physician talked with John, examined him, and did not find anything unusual to suggest something serious. But he decided to order a CT scan of John’s brain, just to be sure that everything was okay.

  It took a long time to complete John’s evaluation that night. Hours really, mostly because of how busy the rest of the emergency department was. Everything was backed up, including the CT scanner and the radiologist who had to read the CT scan. Once the test results were available, it took time for the attending emergency physician to get freed up from caring for other patients in order to review them. That annoyed John even more. Remember, he did not want to be there in the first place.

  But during that time delay, there was actually a bonding opportunity for John…not with his physician, but with his nurse, Jackie. She sensed his frustration and did all she could to make him more comfortable during his time there.

  Jackie closed th
e door of his exam room so that the noise from the rest of the emergency department would not exacerbate his headache. She brought him a warm blanket and turned down the lights in his room so that he could try to close his eyes and get a little rest while waiting.

  And she talked with him. She talked in soft, soothing tones. Clearly, Jackie was the type of person who really cared. She did not just talk with him about the formalities (like chief complaint, history of present illness, review of systems, and all that), but she really talked with him.

  She sensed that there was more to the story. There must have been a reason why he did not want to come to the hospital when his wife insisted. John was notably more relaxed after the care Jackie provided. (By the way, Jackie is a nurse who is known for exceptional care and compassion for patients, so this extra care was nothing out of the ordinary for her on a busy night shift in the emergency department. That’s just who she is. Also, you might think that it takes Jackie extra time for this kind of extra care. In Chapter 8, you will see that is not necessarily the case.)

  After the CT scan was read by the radiologist as normal, John still had a bad headache. But by that time, he’d had it with being in the emergency department. He was ready to get out of there. So the attending physician, seeing that the CT scan was normal, discharged him home. It was 4 a.m. John went home to bed.

  End of story? Not by a long shot.