Compassionomics

  A Compassion Culture Cuts Employee Absences

  Now that you understand how compassion can cut the expense associated with medical errors, overutilization of health care resources, and non-adherence by patients, let’s look at another place compassion makes an important difference: with the well-being of those that take care of patients. Earlier, we looked at how a compassionate culture in a hospital translates into more compassion for patients, but what about compassion for everyone who provides that care?

  You know how airlines advise that, in the event of an in-flight emergency, parents should put on their own oxygen masks first—before attempting to put on a child’s oxygen mask? It’s the same kind of phenomenon at work here. If health care organizations want their health care providers and staff to show compassion to patients, the organizations must first demonstrate compassion to the employees.

  It’s no secret that working in health care can be emotionally exhausting and even sometimes traumatic. If those negative effects are not addressed proactively, people tend to take more sick time and medical leave. Or look for another job that’s not so taxing.

  In a University of Pennsylvania study of health care workers in 13 long-term care facilities (i.e., “nursing homes”), researchers tested this very hypothesis. They asked everyone—including certified nursing assistants, nurses, social workers, physicians, food service personnel and others—to complete a survey that assessed their perception of the workplace culture in their facility.293

  Specifically, they used a validated measurement scale to determine if a compassionate culture was present. It’s important to understand that they were not asking workers to assess their own compassionate behavior, but rather the behaviors of their coworkers all around them.

  What is a compassionate culture exactly? These researchers described it as the way that coworkers helped each other and expressed care for each other…how they were thoughtful about the feelings of their co-workers and shared compassion when things didn’t go well for someone, either at work or in their personal lives.

  But they weren’t only interested in how compassion flowed between two coworkers. They wanted to understand how it flowed in group situations and between supervisors and their direct reports (as well as the degree to which it flowed back to those supervisors).

  Here’s what they found: The emotional culture of the health care facility had a strong association with how employees treated their patients, the patients’ experience, and even patient outcomes. As you might anticipate, employees were not able to effectively show compassion to their patients if they didn’t experience it in their work environment themselves.

  The emotional culture of the health care facility had a strong association with how employees treated their patients, the patients’ experience, and even patient outcomes.

  However, in health care facilities where a more compassionate culture was established, there were better employee outcomes: better experience and teamwork, lower emotional exhaustion, and less absenteeism from work. The improved workplace culture for employees even had a positive impact on the nursing home residents: better quality of life, fewer emergency department visits, and better patient and family experience.293

  This association between a compassionate culture and lower emotional exhaustion among employees is an important finding. One important aspect of emotional exhaustion is when a health care provider loses the ability to feel “compassion satisfaction.” Compassion satisfaction is the degree to which a person feels pleasure from efforts to relieve others’ suffering.

  Doctors who are unable to feel compassion satisfaction due to emotional exhaustion tend to take more sick days and medical leaves of absence. Consider, for example, the findings from a 2013 study of 7,584 physicians.294 It was a survey study to elicit information about both their professional satisfaction and emotional exhaustion.

  Here’s what they found: Among physicians who said they had no compassion satisfaction and were experiencing compassion fatigue (emotional exhaustion, depersonalization, and, in this case, also taking on stress from taking care of those that are stressed from being sick) 68 percent of the physicians had taken a leave of absence due to medical reasons. They also had taken the greatest number of sick days among all the physicians in the study.

  It would be easy to blame the pressures of the health care environment for why a culture with a lack of compassion leads to increased workforce issues. However, there are studies across multiple other industries showing similar results:295

  • 74 percent of employees reported that work is a significant source of stress and one in five has missed work as a result of stress.296

  • 55 percent of employees reported they were less productive at work as a result of stress.296

  • 52 percent of employees reported that they have considered or made a decision about their career such as looking for a new job, declining a promotion, or leaving a job, based on workplace stress.296

  • In 2001, the median number of days away from work as a result of anxiety, stress, and related disorders was 25 days, substantially greater than the median of six days attributable to nonfatal injury and illness.297

  • Job stress is estimated to cost U.S. industries more than $300 billion a year in absenteeism, turnover, diminished productivity, and medical, legal and insurance costs.298

  Dr. Emma Seppälä is the science director of Stanford University’s Center for Compassion and Altruism Research and Education (CCARE) and the author of the book The Happiness Track.299 She often writes about the benefits of compassion in the business setting.

  In an article entitled “Why Compassion in Business Makes Sense,” she sums up the most current data in the field in this way:

  A new field of research is suggesting that when organizations promote an ethic of compassion rather than a culture of stress, they may not only see a happier workplace but also an improved bottom line. Consider the important—but often overlooked—issue of workplace culture…Employees in positive moods are more willing to help peers and to provide customer service on their own accord…In doing so, they boost coworkers’ productivity levels and increase coworkers’ feeling of social connection, as well as their commitment to the workplace and their levels of engagement with their job. Given the costs of health care, employee turnover, and poor customer service, we can understand how compassion might very well have a positive impact not only on employee health and well-being but also on the overall financial success of a workplace.300

  When the work of researchers, such as Dr. Seppälä and her colleagues, on compassion in the workplace is applied to health care—where the intensity of the work and the amount of stress is so high—the results are likely even more dramatic. As a result, the expected economic benefits will likely be magnified as well.

  Investing in Physician Well-Being Pays Off

  Turnover of staff in any organization is costly, when you consider the direct exit costs as well as the additional costs to recruit and train new hires. There is also the decreased productivity of being short-staffed while seeking a replacement and the loss of morale that goes along with people leaving. Then there are other intangibles, such as the loss of institutional knowledge that is missing in new employees when a veteran employee leaves.

  These costs are magnified even further for employees who earn higher salaries, like physicians and nurses. These may include lost revenue (i.e., losing people who bring in revenue) or the recruitment costs of using a professional search firm.

  Let’s take a closer look where there is the most data on this phenomenon in healthcare: physicians. By now, you understand that physician burnout is expensive. It compromises clinical quality and adds significant costs—through medical leave and sick days—for organizations that employ physicians.

  It’s a widespread problem. Burnout affects approximately a half million physicians in the U.S. alone.301, 302 While it’s difficult to calculate with precision, a conservative estimate is that the increase in physician tur
nover that is produced by burnout costs the U.S. health care system approximately $12 billion annually.303 And this is just for physicians.

  So it’s not just that we have a moral responsibility to care for our physicians in the best interest of patients, but we also have a compelling economic imperative to care for those who provide care.

  To that end, some forward-thinking health care organizations are formalizing their efforts to do just that. For example, in a first for an academic medical center, Stanford University hired its first “chief physician wellness officer” in 2017.304 Dr. Tait Shanafelt, who was hired for the job, is a recognized thought leader and researcher on the topic of physician wellness, having led pioneering work on physician burnout and resiliency at Mayo Clinic.

  Later in the same year that Stanford hired him, Shanafelt made a compelling business case for investing in physician well-being in a paper published in JAMA Internal Medicine. In it, he detailed the financial toll that burned out physicians take on a health care system. In addition to factoring in hard recruiting costs and lost revenue during onboarding and lost efficiencies, the cost to a health care organization to replace a physician is two to three times a physician’s annual salary.305

  Plus, when one member of a care team leaves, that physician puts other members of the care team at higher risk for burnout as they work to pick up the slack due to his or her absence.305 So there’s a potential domino effect to worry about in case other team members also decide to leave.

  What makes this even more troublesome is the fact that it’s getting harder and harder to replace physicians who leave, since we’re already facing a shortage of physicians in many specialties today. The burnout epidemic is dangerous, indeed. In one study led by Shanafelt at the Mayo Clinic, they found that the smallest measureable increase in burnout (i.e., just a one point increase on the burnout scale) increased the likelihood—by 30 to 50 percent—that a physician would reduce his professional work effort over the next two years.306

  Cutting back on work seems like a reasonable thing to do when faced with burnout, right? The problem, however, is that the health care system can ill afford fewer physicians. While it’s tempting to think you may just need a little extra time to meditate in the woods—to get your groove back—stay tuned for our upcoming discussion of what really works to create resiliency in Chapter 10.

  Importantly, it’s not just U.S. physicians who are thinking about cutting back because of burnout either. It’s everywhere.

  For example, in a survey study of emergency physicians in the U.K. National Health Service, researchers found that physicians with less compassion satisfaction (i.e., not experiencing pleasure or satisfaction from relieving patients’ suffering) were more likely to complain about patients or colleagues, reduce their quality standards, and even more likely to retire early. (In fact, 59 percent of physicians with low compassion satisfaction were contemplating early retirement).241

  Compassion Lowers Malpractice Costs

  According to an article published in Health Affairs, the annual cost of the U.S. medical liability system, including the cost of defensive medicine, is $56 billion. That doesn’t even include the cost of insurance premiums.307 While it’s a hefty price tag, those costs might be worth it if the system is achieving its goals. And yet, there is scant evidence that’s true. In fact, it is just the opposite.

  In order for malpractice to have occurred, there needs to be a breach of duty to a patient, a deviation from the standard of care, and harm or damage to the patient that has been caused due to that deviation.308 A poor outcome or damage alone does not equate to malpractice.

  Despite how it feels to health care providers, the purpose of the legal system with respect to medicine is not to punish those that commit malpractice. Rather, the purpose of a malpractice lawsuit is to make the patient whole (as if the interaction had not happened) and to incentivize providers to take appropriate precautions against accidental harm.

  Does the U.S. system do either of these things well? No.

  According to a landmark study, the Harvard Medical Practice Study, only 1 in 15 patients who are actually injured due to medical malpractice ever receive any compensation. On the contrary, five out of every six cases that do receive compensation have no evidence of malpractice.309

  These same findings were even reproduced in a second, more recent study looking at the same thing.310 In other words, the overwhelming majority of acts of negligence never become malpractice claims and, at the same time, the overwhelming majority of malpractice claims have no actual occurrence of malpractice.

  This means that patients that are wronged are not getting compensated, and the messages that are being sent to providers about taking precautions are not being heard. As one team of Harvard researchers described it, the malpractice system is “sending as confusing a signal as would our traffic laws if the police regularly gave out more tickets to drivers who go through green lights than to those who go through red lights.”311

  Even with perfect technical expertise or with strict adherence to the standard of care, poor outcomes can occur; that is always a risk in medicine. Poor outcomes alone should not create a malpractice claim that leads to a court case, a settlement or the need to defend anything at all.

  However, patients often ask lawyers to file lawsuits based on poor outcomes. This often leads to malpractice claims despite the absence of the very elements that define such a case. That leads to “tickets for green lights,” using the traffic analogy from the Harvard study.

  So why do patients sue? And what can be done to avoid these lawsuits?

  That’s right…it’s compassion. Yet again.

  A perceived lack of caring – rather than negligence – is frequently what gets a doctor sued. In one study of plaintiff depositions for malpractice lawsuits that were settled against a large metropolitan medical center, researchers found that, in general, patients and families decided to litigate because they perceived their doctors didn’t care.312

  Specifically, they complained that doctors weren’t available, they discounted their concerns, they weren’t good at conveying information, and they just didn’t seem to understand the patient’s or family’s perspective. It wasn’t the technical part of the medical care; it was the caring part of the medical care.

  A perceived lack of caring – rather than negligence – is frequently what gets a doctor sued.

  A study of new mothers’ experiences with their obstetricians by researchers from Vanderbilt University uncovered the same finding.313 They interviewed nearly a thousand new mothers and analyzed the data based on the malpractice history of their obstetricians. They separated the physicians into those that had a large number of malpractice cases in the past (i.e., the “high malpractice” group) and those that had low to no malpractice history in the past.

  They wanted to learn about the relationship between malpractice history and the doctor-patient relationship with the obstetrician. Would physicians that got sued more often reveal a different pattern in the way they treated their current patients?

  Although none of the women in the study had an active malpractice claim against their obstetrician, researchers were nonetheless struck by the emergence of a clear pattern. Compared to patients of obstetricians with low or no malpractice history, the patients of obstetricians in the high malpractice group complained they felt rushed, didn’t receive good explanations about recommended tests, and were often ignored.

  In fact, when the patients were asked to share which part of their care had been the least satisfying, the patients of high malpractice obstetricians had a list of complaints twice as long as the patients of obstetricians with low/no malpractice history. At the top of the list of these moms’ complaints was poor physician communication.

  Remember our earlier discussion about the relationship between compassion and trust? When a health care provider authentically expresses compassion, it’s likely that he or she is also making eye contact and giving lots of verbal and non-verb
al cues that he cares about the patient. That’s what confers trust. The absence of that type of communication creates distrust…and those are the patients who sue.

  Several studies have suggested that the doctor-patient relationship—or lack of it—is a major determinant, if not the deciding determinant, of a patients’ overall assessment of their treatment, and, therefore, a major factor in the decision to pursue a malpractice claim.314, 315, 316, 317, 318, 319

  None of these studies, however, used an experimental design—like a randomized controlled trial, for example—which is the more definitive way to show cause-and-effect in research. But researchers at the University of California San Francisco designed just such a study with obstetric patients (the population of patients most likely to file a lawsuit in the event of an adverse outcome).320

  Women who had delivered babies within the last six to 12 months were enrolled in the study and were randomly assigned to consider one of four hypothetical scenarios describing interactions between a patient and an obstetrician throughout a patient’s pregnancy, labor, and delivery. Essentially, they were asked to imagine themselves in the scenario described, where there were ultimately complications with childbirth, and explain how they would feel.

  Multiple different communication behaviors of the physician were described in these scenarios as well as different severities of complications for the baby, some of them quite disabling. One of the questions asked was “Given what happened in the pregnancy described earlier, I would be likely to file a malpractice claim against the physician (yes/no).”