Compassionomics

  The findings? In scenarios describing a strong doctor-patient relationship, the participants were more likely to believe that the obstetrician was competent and not at fault for the occurrence of the complications of childbirth. As a result, these women were less likely to express intentions to file a malpractice claim, even in cases where the outcomes for the baby were more severe.

  In summary, a take-home message for health care providers: When patients suffer bad outcomes, whether or not you get sued may not be based on how you treated patients (i.e., the technical aspects) but rather how you took care of them.

  Could Compassion Increase Costs?

  As stated at the very outset of this book, being both data-driven and open-minded are prerequisites for good science. So in addition to a willingness to accept the hypothesis that compassion might not make a difference, there must be a similar willingness to examine the possibility that compassion might cause harm in certain circumstances.

  This was a particular possibility when it came to examining the effect of compassion on costs. Would a more compassionate physician with a stronger doctor-patient relationship understand the patient’s situation more and, as a result, order more tests and referrals? You’ve seen that the evidence shows that just the opposite is true.

  But then an emergency medicine colleague of ours pointed out a very common scenario—one in which emergency department staff almost universally believe that compassion drives up costs: the homeless patient. It’s frequently an individual who comes to the emergency department with no identifiable diagnosis. It’s presumed he is there just looking for a warm place to sleep for a while.

  This is a very common scenario. In fact, these patients typically return to the emergency department repeatedly, sometimes several times per month. The logic of the emergency department staff is that since federal law mandates that every patient must be seen, these patients know that they will have some amount of time sheltered.321

  Sometimes nurses and staff are actually reluctant to be kind to these patients. They may be slow in calling them from the waiting room in a timely manner or hesitant to offer them some small amount of hospital food. Their fear is that such kindnesses might send the wrong message…making them more likely to return, even though they do not actually need medical care.

  It’s not that these nurses and staff are cold, heartless individuals, of course. They’re just doing their best to make sure there are beds available in the emergency department when truly sick patients arrive and urgently need them. They don’t want anyone to be gaming the system.

  The logic is sound here, but the science tells a different story.

  In a fascinating randomized controlled trial from the University of Toronto that appeared in the The Lancet—one of the most prestigious clinical journals in the world—researchers tested if especially compassionate care for homeless patients in the emergency department would affect their subsequent use of emergency services.322

  They randomized 133 homeless patients arriving in the emergency department with no identifiable diagnosis into two groups: one group was assigned to receive extra compassionate care from a trained volunteer (a person whose only job was to treat the homeless patients with extra compassion) in addition to usual care from the emergency department staff. The other group was assigned to usual care only. They tested the association between extra compassion and return visits to the emergency department over the next thirty days.

  Extra compassion reduced subsequent emergency department visits by homeless patients by 33 percent.

  And what did they find out? Compared to usual care, randomization to extra compassion reduced subsequent emergency department visits by homeless patients by 33 percent. These results are based on a randomized trial with a rigorous experimental design. So they are based on science; not a set of beliefs or opinions.

  What could be the explanation then for why the homeless patients did not return to the emergency department as often after receiving extra compassion? The authors postulate that perhaps the patients just finally got what they wanted: someone to care.322

  Shouldn’t compassion be the default—rather than the exception—when interacting with patients? When interacting with anyone?

  There’s simply no reason—neither moral nor scientific—whether you’re considering the art or the science of compassion, to ignore the profound benefits it confers.

  CHAPTER 8:

  The Power of 40 Seconds

  “Be kind whenever possible. It is always possible.”

  —Dalai Lama

  One reason health care providers don’t show compassion is because they’re concerned it’s going to take time they just don’t have. After all, time is money in health care, right?

  Time is clearly a crucial factor in the efficiency and the economics of health care. So does it really take a lot more time to show patients compassion?

  Researchers found that 56 percent of physicians believe they do not have time to treat patients with compassion.

  As you saw earlier, health care providers frequently feel they’re just too busy for compassion. More than half of physicians feel this way, according to one Harvard Medical School study: 56 percent of them, specifically, believed that they do not have enough time to treat patients with compassion.323

  But why are health care providers so frenetically busy these days? For one reason, there is a continuous push for them to see more patients in less time. This is often a financial pressure, because payments from insurers to health care organizations are generally going down, and the costs of running a health care enterprise keep going up.

  Another reason for health care provider “busyness” is what many consider to be the “red tape” of health care. There’s been a sharp increase in the demands for documentation of the care that physicians provide.

  To avoid fines or losses in revenue, health care organizations must comply with an ever-increasing list of rules and regulations that document compliance. That burden lands squarely on the shoulders of the people providing care to patients. In fact, many health care quality metrics tracked by the federal government rely solely on this documentation.

  Another time suck is the increased demand for administrative tasks to satisfy payers. There’s always one more process required to get patients the care they need. Lots of time is spent on obtaining prior authorization for services or appealing denied services. This ever-increasing administrative burden makes it particularly challenging to see more patients in shorter time intervals.

  But seriously? No time for compassion? Compassion for others is supposed to be one of the main reasons that providers choose to go into the health care profession in the first place!

  This begs the very important question: How much time does it really take? So let’s consider the scientific data for how much time is really required to make a compassionate connection with a patient.

  Spoiler alert: The evidence may surprise you.

  It’s Time to Take the Time

  To address the question of time, researchers from Johns Hopkins University performed a randomized controlled trial in cancer patients during a consultation with an oncologist.97 The main outcome measure for this study was a well-validated measurement scale for patient anxiety. If you understand what it’s like to receive a cancer diagnosis, then you already know that reducing anxiety is a critically important outcome for cancer patients.

  The researchers found that, compared to a standard consultation from an oncologist, patients randomized to an enhanced compassion intervention from an oncologist had significantly less anxiety at the end of the consultation.

  So what was the enhanced compassion intervention? It was a few words offered at both the beginning and the end of the consultation.

  Here was the message from the oncologist, at the beginning of the consultation:

  “I know this is a tough experience to go through and I want you to know that I am here with you. Some of the things that I say to you today may be difficult to u
nderstand, so I want you to feel comfortable in stopping me if something I say is confusing or doesn’t make sense. We are here together, and we will go through this together.”

  And then at the end of the consultation, the oncologist said:

  “I know this is a tough time for you and I want to emphasize again that we are in this together. I will be with you each step along the way.”

  So how long did it take? They timed it: just forty seconds.

  Patients that were randomized to this enhanced compassion intervention and heard these messages from the oncologist rated the oncologist as warmer and more caring, as well as sensitive and compassionate. Patients in the enhanced compassion group also rated the oncologist higher in terms of wanting what was best for the patient. But what was most striking was that, using a validated scientific scale to precisely measure patients’ level of anxiety, patients randomized to the enhanced compassion intervention actually had measurably lower anxiety.

  This randomized controlled trial demonstrates two important things: First, in accordance with what you already learned in Chapter 4, compassion for patients can effectively reduce the anxiety they are experiencing, thereby improving their psychological health. Second, and perhaps most importantly, forty seconds of compassion is all you need to make a meaningful difference for a patient.

  Forty seconds of compassion is all you need to make a meaningful difference for a patient.

  But are these results from Johns Hopkins—that it only takes forty seconds—the exception or the rule? Let’s take a look at more data:

  In two studies from the Netherlands Institute for Health Services Research, researchers tested the effects of compassionate communication on patient anxiety among patients receiving “bad news” about their diagnosis and prognosis (e.g., a terminal condition).174, 175 Of note, this study had to be conducted in a sample of “analogue” patients—healthy patients who put themselves “in the shoes” of a patient receiving bad news—because, of course, it would be unethical to randomize a patient receiving such bad news to a lack of compassion.

  As a reminder, numerous scientific studies have shown that use of analogue patients is not only a valid, but actually an optimal method for studying the effectiveness of health care provider communication with patients, so we can have confidence in the study results.251

  Half of the study subjects receiving bad news were randomized to standard communication from the physician and the other half were randomized to an enhanced compassion communication from the physician.

  The enhanced compassion intervention included all of the following communications from the physician:

  “Whatever we do, and however that develops, we will continue to take good care of you.”

  “We will be with you all the way.”

  “We will do, and will continue to do, our very best for you.”

  “Whatever happens, we will never abandon you. You are not facing this on your own.”

  “Together, we will have a careful look at decisions you have to make and will keep a close eye on your concerns.”

  Similar to the Johns Hopkins study, the researchers found that participants who were randomized to the enhanced compassion communication had significantly lower anxiety following the consultation, as measured on a validated anxiety measurement scale.

  But here is the most important piece of data: How long did this enhanced compassion communication take in total? Again, they timed it: just 38 seconds. Similar to the findings of the Johns Hopkins study, 38 seconds was all it took to make a meaningful and measurable difference.

  What about Endless Concerns and Questions?

  A skeptic might critique these data as being one-sided, only reflecting the health care providers’ part of the communication. What about the patient side of the communication? When you factor that in, doesn’t compassion take a lot longer?

  Health care providers sometimes express concerns that if they start regularly exploring their patients’ emotions, it might open up “Pandora’s box” of endless concerns, where it seems like the patient will never stop talking, and so the provider won’t be able to get his or her work done efficiently. As we saw in the Harvard Medical School study at the beginning of this chapter, 56 percent of physicians believe that they do not have time to go down this path of exploring emotions with their patients.323

  But the available data in the biomedical literature do not support this thinking. In fact, when precisely measured, the scientific data support that a compassionate exchange with a patient actually takes far less time than one might think.

  For example, researchers from Northwestern University studied real-world patients in a general internal medicine practice, using a validated methodology to measure compassion opportunities from patients and the corresponding responses by physicians.324

  They identified these as “opportunity-response” communication sequences. They found that compassionate opportunity-response communication sequences took, on average…31.5 seconds.

  Compassionate opportunity-response communication sequences take about 30 seconds.

  This 31.5 seconds included hearing what the patient had to say that presented an opportunity for compassion, plus the health care providers’ response, including “confirmation” (conveying that the patients’ emotion or concern was legitimate) or “pursuit” (asking the patient a follow-up question or offering support).

  So this time sequence included both the patients’ part of the communication as well as the physicians’. On average, the exchanges with the most compassion—including confirmation or pursuit—took about half a minute.

  Now, to be fair, if there was a long series of compassionate opportunity-response sequences between the patient and the physician, it could be longer. For example, if a patient was really struggling on a particular day and was especially in need of compassion, a back-and-forth exchange of ten compassion sequences between the patient and the physician could then take, on average, 315 seconds (31.5 seconds per sequence for 10 sequences).

  But even still, let’s recognize that those ten sequences add up to barely over five minutes in total. And the available evidence indicates that this level of need for compassion would be an outlier or extreme case.

  The truth is that patients in some medical visits do not communicate any need for compassion during their visits, and so, may not even require the extra thirty seconds. In the Northwestern study, for example, many of the clinic visits had zero compassion opportunities.

  But among all clinic visits with one or more compassion opportunities, the mean number of compassion opportunities per visit was 2.5. Think of it like this: If a compassion sequence takes, on average, 31.5 seconds and there are 2.5 sequences per patient, providers can expect to spend an extra 79 seconds (on average) with a patient who is in need of compassion.

  So if a single sequence of communicating compassion probably takes half a minute, can health care providers spare that for compassion? How about a whole forty seconds, as in the Johns Hopkins study?

  Does Compassion Lengthen Doctor Visits?

  The findings in these studies are also corroborated by other rigorously conducted research that shows compassionate care does not add a significant amount of time to a health care encounter. In Chapter 4, for instance, you saw the data from a University of California San Francisco study of inpatients admitted to the hospital, where each additional compassionate statement from a hospitalist physician was associated with an incremental (or cumulative) reduction in patient anxiety.48

  In that study, researchers also measured total encounter time—the length of time physicians spent face-to-face with patients—and found that the number of compassionate statements from the physician was not significantly associated with encounter length. More compassion did not equate to longer visits. So the data support that being compassionate does not add a significant amount of time to the total time spent with patients.

  Similar results have been found in studies of patients in the primary
care setting. In a study supported by the National Institutes of Health (NIH), researchers from Johns Hopkins University conducted a randomized controlled trial of compassionate communication training (including “emotion handling” skills) for physicians.185

  They found that, compared to a control group of primary care physicians who received no special training, the physicians randomly assigned to training in emotion handling had higher ratings for compassionate care from patients, and their patients were less emotionally distressed. And here’s an amazing finding that probably surprised the authors of this study: In follow-up evaluations by telephone, they learned that compassionate care not only reduced patients’ emotional distress, but the effects also persisted up to six months after the clinic visit.

  But the researchers were also interested in the time during clinic visits that it took to get those kinds of benefits. So they measured the time that the physicians spent face-to-face with patients in the initial appointment. The hypothesis was that it might take more time in order to make a compassionate connection.

  What they found is that the compassion-trained physicians did not spend significantly more time. It was slightly longer, but the difference was so small that it was not statistically significant. Compared to a control group of physicians who did not get any special training, the clinic visits with the compassion-trained physicians were, on average, only 54 seconds longer.

  Lower emotional distress for six whole months from just 54 seconds of extra care? That’s a lot of mileage from less than one minute of compassion!