Compassionomics

  The Power of Mindset

  So now you have seen the data that compassionate behaviors can, in fact, be learned and that compassion training works. But there is a key characteristic that’s required for success: the learner’s mindset.

  You may be familiar with the research on “growth mindset” from Dr. Carol Dweck and her colleagues at Stanford University. In her book Mindset: The New Psychology of Success, Dweck explains how a vital part of learning new things is the belief that you can. You must believe that change is possible.356

  According to Dweck, many people believe that successful learning is based solely on innate ability. She describes such people as having a “fixed” theory of intelligence, or a fixed mindset. Others, who believe that successful learning is based on hard work, training, and perseverance are said to have a “growth” theory of intelligence, or growth mindset.

  Here’s why that’s so important for learning new things. “Fixed mindset” people believe their abilities are fixed traits. They dread failure because they believe that it exposes their inherent lack of ability. As a result, they do not eagerly take on new challenges because of their fear of failure and looking or feeling stupid.

  On the contrary, “growth mindset” people understand that their abilities grow through good teaching, effort, and persistence. They do not fear failure because they recognize that is how learning happens. You need to work at it.

  As a result, such individuals are inherently more eager to take on new challenges and grow in their abilities. Dweck’s research has shown that, over time, these types of people are more likely to be successful in whatever they are trying to accomplish.

  Most of Dweck’s work has been on learning and education in the broad sense. But could these principles also apply to learning to be compassionate to others? The answer is yes.

  Growth mindset is crucial for becoming a more compassionate health care provider, or more broadly, a more compassionate person. Not just one, but a whole series, of studies from Dweck and colleagues found that in contexts where being compassionate is challenging, people who hold a growth mindset about compassion (believing that compassion can be developed) put significantly more effort into being compassionate, compared to people who hold a fixed mindset (believing compassion cannot be developed).357

  A person’s mindset powerfully affects whether they exert effort to be compassionate when it is needed most.

  The researchers found that people with a growth mindset worked harder at being compassionate because they had a stronger interest in improving their compassionate behavior. These studies indicate that a person’s mindset powerfully affects whether they exert effort to be compassionate when it is needed most.

  The data you’ve reviewed here have demonstrated quite clearly that one can learn to treat others with compassion; however, one must have a growth mindset to realize this change. You must first believe in your mind that change is possible!

  You Gotta Want It

  So if health care providers understand that change is possible, can’t health care organizations and administrators just mandate that their providers participate in compassion training programs and work hard at being more compassionate to patients?

  Nope. And this part is critically important for administrators of health care organizations to understand.

  Science shows that health care providers have to want to get better at compassion. Compassion cannot be mandated.

  Health care providers have to want to get better at compassion. They have to have intrinsic motivation for improving, rather than extrinsic motivation, like being forced to do it. That’s what the science shows.

  In a series of studies that were designed to test the importance of intrinsic motivation in helping others, researchers from the University of Rochester found that the degree to which helping others is “autonomous” (i.e., voluntary), rather than “controlled” (i.e., mandated or forced), predicts the effectiveness of help—as perceived by the receiver.358 In other words, receivers of help perceive the help to be more effective when the helper is doing it because they want to. Maybe that’s because people do a better job of helping when they intrinsically want to help, rather than it being forced upon them.

  This is why health care administrators can’t just mandate health care providers to be compassionate to patients. That’s not how compassion works. For patients to really benefit from compassion, the health care provider behaviors need to be self-initiated (or self-endorsed).

  But here is an even more interesting part of what the University of Rochester researchers found: The degree to which help was autonomous (versus controlled) predicted the effects of helping on the well-being and self-esteem of the helper.358 So helpers that intrinsically want to help are not only more effective at it, when they offer it freely (versus being forced), they feel better about the experience of helping.

  In the next chapter, you will see more about how compassion for others powerfully impacts health care provider well-being and resilience. But for now, just remember that compassion can’t and shouldn’t be forced upon health care providers. Rather, help them to understand the “why” behind compassionate care so that they want to use compassion in every opportunity that they have.

  Understanding that “why” is what this book is all about.

  Learning to Care When Caring is Hard

  During busy shifts or challenging days, it can be easy for health care providers to lose sight of the people they’re caring for…not just a person’s clinical diagnosis or symptoms, but all of the things that make them unique, important, and beloved to the people in their lives. Sometimes disease can ravage a body and make that harder for health care providers to see.

  Nicki was a perfect example of that.

  She was beautiful. Long brown hair. Kind eyes. A radiant smile that could light up the room. Her high school graduation portrait was picture perfect: a girl happy and full of life who brought happiness to those around her. It was a picture of a girl ready to take on the world…with her whole life ahead of her.

  Things are much different today. That graduation photo sits on the windowsill in her room in the ICU, a poignant reminder to those caring for her of what her life used to be. Nicki’s mom, Susan, brought the picture in, along with some baby pictures. The beautiful smile of that toddler was the same one as in the graduation photo. It was unmistakable.

  It’s hard for Nicki’s caregivers to see her distinctive smile in the ICU today, with all the tubes and medical equipment. She has been unconscious on a ventilator for days with no sign of improvement. The reality of today is light years away from that graduation photo. She is almost unrecognizable.

  Nicki has also withered away to less than 100 pounds. She is so emaciated that the beautiful face from the graduation photo is now sunken and sallow. The dirt on her feet was so deep-seated that despite repeated scrubbing by the ICU staff, her feet still tell a story of homelessness and being on the streets for way too long.

  Covering her arms is the evidence of what caused her to abandon her home after high school. Years of injecting drugs into her veins have left awful scars on her body.

  Nicki may never wake up. And if she does, she may never be able to communicate…to tell her mom how sorry she is for all the pain and anguish she’s caused or how much she loves her, despite all the battles they’ve been through during all the times Nicki bounced from rehab to home and then, inevitably, back out on the streets again.

  Susan knew she would get that dreaded phone call one day. She had been called to the hospital many times for Nicki’s overdoses, and the repeated bloodstream infections that came from her heroin injections. She knew that one day she would get the call that would change everything.

  She received that call one week ago. Since then, Nicki has not opened her eyes. Twenty five year-olds are not supposed to have strokes…let alone massive strokes. But when infections in the bloodstream collect on the valves of the heart, those big chunks of bacteria can break off and quickly
migrate into the brain to cause a massive stroke, as they did for Nicki—changing the trajectory of her life instantly and forever.

  As the reality of it all begins to sink in, Susan shares the story of another heartbreak in this very same ICU: when her older brother died several years ago from liver failure. She describes him as kind, gentle and outgoing, the kind of guy who would do anything for anybody. But privately, he battled demons. He could not stop drinking.

  Jared spent a month in the ICU before he died. Susan recalls that whenever the doctors would do hospital rounds and discuss his case, the resident physician’s opening sentence always described him as “a 53-year-old alcoholic with liver failure.” To them, that was who Jared was. That hurt her a lot.

  She knew him very differently. She knew him as a loving brother who was with her always as they were growing up, in good times and bad. He was her rock. Susan misses him desperately, especially now when she has to face saying goodbye to Nicki. She has no one left to lean on.

  Just as she did during Nicki’s hospitalization, Susan recalls also propping up Jared’s graduation photo and baby picture on the ICU windowsill in a desperate attempt to help the nurses glimpse her brother the way she still sees him in her mind’s eye…before addiction ravaged his body and made him unrecognizable, too.

  She mentions overhearing doctors and nurses sometimes refer to Jared’s condition as “self-inflicted”—just as they have with Nicki’s. As if they both deserved the suffering they were experiencing.

  This, too, hurt her a lot.

  Stories like Nicki’s and Jared’s play out in hospitals around the country daily. While these kinds of statements from staff aren’t very compassionate, perhaps we shouldn’t be surprised.

  There is extensive data in the psychology scientific literature to show that people’s compassion for others often drops—sometimes rather sharply—when they believe that poor choices played a major role in the condition an individual is in; they believe they did it to themselves.

  And in its simplest form, it’s true. When a person’s body is ravaged by the effects of addiction, that individual has clearly made some poor decisions—perhaps repeatedly—and especially in the beginning.

  But today there is simply no longer a debate about whether addiction is a disease or a choice. Medicine has firmly concluded that addiction is a disease.359

  It is critically important to recognize that, in the history of the world, no one has ever awakened in the morning and said to themselves, “Hey, I’ve got a great idea! Today I’m going to go out and get addicted to heroin.” Or alcohol. Or anything else for that matter. That’s just never happened.

  If you’ve ever witnessed someone’s body destroyed by the effects of addiction, you know how ugly it is. At the very end, they are unrecognizable. They suffer unspeakable pain. No one would ever willfully intend to be in that horrifying place. And thinking that they would makes it that much harder to summon the compassion needed to provide compassionate care.

  But this idea that patients “do it to themselves” also extends far beyond patients who struggle with addiction. What about morbid obesity, for example? Some providers might be judgmental toward a morbidly obese person—because they believe such a condition results from bad personal choices and a lack of willpower.

  It’s not. It is far, far more complex than that.

  Morbid obesity destroys a person’s health. And when he is lying there in the hospital bed, with his life slipping away due to the cumulative effects of obesity on his body over many years, he too suffers unspeakable pain. No one would ever willfully intend to be in that horrifying place.

  And what about people who don’t take their medicine? Or follow doctors’ orders? The so-called “non-compliant” patients. These patients are repeatedly readmitted to the hospital because they do not (or cannot) adhere to treatment recommendations. Do they “deserve it,” too?

  Maybe the reason why a patient doesn’t refill his medication prescriptions to maintain better health is because he’s used every dollar he has to make sure his kids don’t go hungry. Poverty brings difficult decisions.

  Or maybe it’s because of mental illness. Or maybe health care providers have never really done a good job of explaining things in a way he can understand.

  No one would ever willfully intend to be admitted to the hospital over and over again.

  So let’s be clear about one thing: When a person’s health is failing and he or she is suffering terribly, remember this:

  No one “deserves it.” Ever.

  You’ve seen the scientific data that people can, in fact, learn to be compassionate to others. But it’s not enough to simply learn compassionate behaviors. Or to have a growth mindset. Or to believe that change is possible.

  Before one can learn to be more compassionate, there is a vital first step. First, one must believe that every patient deserves compassion.

  Every single one.

  A Final Few Thoughts: If We’re Being Honest…

  In case you’re thinking that we must be the most compassionate doctors in the world, wonder no longer.

  Just because we’re sharing revolutionary scientific truths about the power of compassion here doesn’t mean that we never slip ourselves. The truth is: We are both very much “works in progress.” But we see it now. And what you focus on always grows stronger.

  We used to believe that people were either wired for compassion or they were not. But the data in the scientific literature don’t lie. The data—for both in the general population and in health care workers specifically—show that compassionate behaviors can most definitely be learned. And that is good news.

  So we are working hard to get better at compassion—every day.

  And last, a final note on tongue rolling: It’s time for some more myth busting. It turns out that Dr. Sturtevant, and hence your junior high school science teacher, was actually wrong. Not only have rigorous scientific studies (conducted in twins and families) shown quite clearly that tongue rolling is not an inherited trait, but they have also found that tongue rolling can actually be learned!360, 361, 362, 363, 364

  CHAPTER 10:

  Compassion as an Antidote to Burnout

  “If you want others to be happy, practice compassion. If you want to be happy, practice compassion.”

  —Dalai Lama

  It’s true. Compassion is not only a powerful therapy for the person receiving compassion, but it is a powerful therapy for the person giving compassion, too. That’s what the latest science shows. And that’s why compassion can be such a powerful treatment for burnout among health care providers.

  Burnout: A Public Health Crisis

  Earlier, you learned that two cornerstones of the burnout syndrome are depersonalization—the inability to make a personal connection—and emotional exhaustion, which is an important precursor to compassion fatigue.

  When depersonalization and emotional exhaustion are present, it’s no wonder that patients experience a lack of compassion. In fact, depersonalization and emotional exhaustion act as important surrogate markers for an absence of compassion when researchers study the effects of the compassion crisis on patients and patient care.

  You’ve also read about the link between burnout among health care providers and lower quality of care (Chapter 6), including major medical and surgical errors as well as how health care providers “cut corners” in the care of patients.365 In fact, new research from the Mayo Clinic demonstrates that burned out physicians have two times higher odds of making major medical errors.366

  This is true cause for alarm because medical errors have been identified as a leading cause of death in the U.S. In short, health care provider burnout takes a toll not just on the people providing care, but the human toll also includes devastating effects on patients as well.367

  You’ve also learned about the dire financial implications of burnout (Chapter 7), including the billions of dollars in direct costs and lost productivity for those that are harmed through
medical errors and the ways in which burnout is associated with higher costs of care, especially with respect to physician and employee turnover. (The latter is estimated at $12 billion annually for physicians alone).288, 301, 302, 303

  We also described the link between burnout and lost revenue to health care organizations that results from the effect of burnout on patient experience. (That’s key because patient experience is one of the main drivers of the “business” of health care.) So you already understand the economic toll of health care provider burnout on the financial sustainability of organizations and our health care system overall.

  Research shows that approximately 50 percent of U.S. physicians are suffering from burnout.

  Through your own experience, you may also be aware that the prevalence of burnout symptoms among health care providers is enormous and growing rapidly. The medical literature supports this. For example, based on rigorous research using validated measures of burnout, multiple independent researchers have found that approximately 50 percent of U.S. physicians are suffering burnout symptoms.30, 301

  The National Academy of Medicine (NAM) concurs.368 The NAM is a branch of the National Academies of Sciences whose aim is to provide unbiased, evidence-based, and authoritative guidance on health policy to policymakers and leaders in every sector of society and the public at large. The NAM sees burnout for what it is: a crucial problem for public health.