Compassionomics

  Higher compassion is associated with lower depression symptoms, a higher sense of personal accomplishment, and enhanced quality of life.

  A follow-up study from the same group of Mayo Clinic researchers, using similar methodology, examined more than a thousand medical students in a multi-center study.410 The researchers found an inverse association with compassion; students with high compassion had low burnout and vice versa. Higher compassion was also associated with lower depression symptoms, a higher sense of personal accomplishment, and enhanced quality of life.

  And this isn’t true only for medical students, either. There is substantial evidence that an inverse relationship also exists between compassion and burnout among practicing physicians. A survey study of 7,500 physicians found that those who had the lowest compassion satisfaction (i.e., the least amount of pleasure from compassion for others) had the highest burnout and personal distress.294

  These physicians with low compassion satisfaction also missed the most days of work and were more likely to take a medical leave of absence. The researchers found significantly less personal distress among physicians who had high compassion satisfaction (i.e., experienced pleasure from compassion).

  In an eye-opening study of 294 primary care physicians, researchers found that in a multivariable model controlling for potential confounders, physicians’ compassion was independently associated with lower physician burnout.411 The researchers concluded that physician compassion may be protective against burnout.

  But what about under really stressful conditions, like in the emergency department? Being an emergency nurse is unquestionably one of the hardest jobs in health care. Among emergency nurses, researchers have found that more compassion is associated with higher scores for nurse well-being.412

  It appears that when health care providers are under the most stress, that compassion is needed the most for their own well-being.

  Similarly, researchers have found that among emergency physicians, the ability to maintain compassion for patients was a distinguishing feature of satisfaction in their professional quality of life.241 It appears that when health care providers are under the most stress, that compassion is needed the most for their own well-being.

  Most of the studies mentioned here are observational studies looking at associations between compassion and burnout. As has been mentioned multiple times in earlier chapters, the most compelling evidence comes from research with an experimental design where prescribed interventions are tested.

  So are there any such studies looking at compassion and burnout? Yes.

  One such study from the University of Rochester, published in JAMA, trained seventy primary care physicians in techniques to be fully present and attentive with their patients over an eight-week period.413 The researchers found that this experience raised the physicians’ belief in the importance of compassion as well as their self-ratings of their own compassion. But that’s not all: They also found that the physicians’ burnout symptoms decreased while their scores for well-being increased.

  A recent randomized controlled trial of compassion training from Emory University holds some of the most persuasive scientific data on the power of compassion for the giver.414 In a group of 132 physicians-in-training, the researchers randomized the participants to a ten-week compassion training program versus assignment to a waitlist (which was the control group).

  They found that students randomized to compassion training not only developed more compassion for others, but they also experienced a decrease in any symptoms of depression that they might have had. Further, the effects on their depression symptoms were found to be the greatest among those who had the highest level of depression symptoms at baseline, suggesting that compassion training may benefit those most in need by breaking the link between low compassion and personal suffering.

  Relationships Matter

  When it comes to healing burnout, the Dalai Lama perhaps expressed it best when he advised: “Cultivating a close, warm-hearted feeling for others automatically puts the mind at ease. It helps remove whatever fears or insecurities we may have and gives us the strength to cope with any obstacles we encounter.”

  So how does a culture of compassion in the workplace impact the well-being and risk of burnout among health care workers?

  Think back to the University of Pennsylvania study of 13 long-term care centers (nursing homes) from Chapter 7.293 In that study, you will recall that they surveyed the health care workers using a validated instrument to determine if there was a culture of compassion in their workplace.

  Researchers also measured the health care workers’ emotional exhaustion, which is a key component of burnout. They found that a compassionate culture in the workplace was associated with less emotional exhaustion among these health care workers. Clearly, relationships matter. In this study, being a part of a compassionate workplace culture transformed these workers’ experience and lowered their risk of burnout.

  In a similar study from Virginia Commonwealth University, researchers measured compassion practices across thirty different outpatient clinics in an academic health system, as assessed by 177 nurses who worked there.415 They also measured emotional exhaustion and psychological vitality among the nurses, as well as patient experience.

  In assessing compassion practices across the thirty clinics, the nurses were asked if employees were recognized and rewarded (through an awards program) for acts of caring shown to patients and families or for acts of caring shown to coworkers. They were also asked if there was a culture of supporting employees through difficult times or workplace stress.

  What they found is that a compassionate workplace culture was associated with lower emotional exhaustion and better psychological vitality among the nurses. And there is evidence that this culture also impacted nurse behavior towards patients: Where there was a compassionate workplace culture, the patients perceived greater caring by nurses.

  The evidence suggests that patients feel a compassionate culture in the health care workplace and this is associated with better well-being among the nurses providing that greater care and compassion. In summary, the data suggest that a culture of compassionate care can be a virtuous cycle—resulting in more compassion for those being served and better well-being for those who serve.

  These data on a compassionate culture, and the meaningful relationships that flow from it, make sense if you think back to Chapter 3 and the Harvard Study of Adult Development.416 That’s the ongoing study that has been in progress for over eighty years now in which researchers have found that good relationships were a better predictor of people’s health than traditional medical markers such as cholesterol levels.86

  In fact, it was the people who were the most satisfied in their relationships with others at age 50 that were the healthiest at age 80. It appears that relationships matter in the context of health care providers as well.

  In a study of physicians-in-training, researchers from Thomas Jefferson University similarly found an inverse association between compassion and burnout that was impacted by personal relationships.417 They learned that higher compassion was associated with lower burnout and concluded that this was because compassion for others is conducive to relationship building, which builds personal resilience. Multiple other studies of physicians (and physicians-in-training) have also found an inverse association exists between compassion for others and burnout symptoms.32, 418, 419

  So human connection and meaningful relationships may be a mediator of the association between high compassion and low burnout in trainees just beginning their careers, but what about the opposite end of the spectrum? What about for established physician leaders?

  An interesting study from Dr. Kandi Wiens at the University of Pennsylvania, highlighted in Harvard Business Review, shines a light on the importance of practicing compassion for others among physician leaders (administrators) in health care organizations.420, 421, 422

  Specifically, Wiens’ research used structured intervie
ws and a rigorous qualitative research methodology to study stress and burnout in 35 physicians who were chief medical officers (CMOs) of large hospitals and health systems. What Dr. Wiens and colleagues found was that 69 percent of CMOs had stress that was “severe,” “very severe,” or “worst possible.”

  And yet, despite all this stress, the majority of CMOs were actually not suffering from burnout. In general, burnout among CMOs was much lower than expected.

  What did the researchers find was the key ingredient to the CMOs resilience from extreme stress? It was compassion for others! They found that for 91 percent of CMOs, actively practicing compassion for others in their CMO roles reduced or counteracted their stress and also reduced their risk of burnout. They found that compassion was one of the CMOs’ secrets for resilience.

  Physicians who had the most dissatisfaction with the quality of their relationships with patients had a 22-fold higher risk of burnout.

  There is more compelling data that the relationships physicians have with their patients matters for the well-being of physicians. In a cross-sectional study of 839 physicians across multiple specialties, researchers found that physicians who had the most dissatisfaction with the quality of their relationships with patients had a 22-fold higher risk of burnout.423

  Another study found that among primary care physicians, high emotional intelligence of the physician was associated with not only better patient experience, but also higher physician professional satisfaction and lower burnout.424 These data support that connecting with patients in a meaningful way produces a better patient experience that can also transform the physician’s experience in a meaningful way. And that leads to lower risk of burnout.

  Similarly, other research—in primary care physicians, specifically—has identified that compassion for patients is a vital contributor to professional satisfaction.425 Also notable: Research demonstrates that a minimum level of compassion is needed for a physician to benefit from the positive aspects of professional fulfillment and quality of life in the practice of medicine.426

  Compassionate physicians are more likely to be considered a “role model.”

  In case you were wondering, there is evidence that colleagues take notice when health care providers are especially compassionate. In fact, a study from Johns Hopkins University, published in The New England Journal of Medicine, found that compassionate physicians are more likely to be considered a “role model.”427

  The researchers asked Johns Hopkins resident physicians to name the supervising attending physicians that they believed to be the best role models. They then studied all attending physicians to determine which qualities were the most admirable.

  They found that attending physicians who consistently stressed the importance of a compassionate doctor-patient relationship in their teaching had 2.6 times higher odds of being perceived as a role model by the trainees. Certainly, being thought of as a role model can enhance professional fulfilment, well-being, and a sense of purpose in a physician’s career.

  Compassion for Yourself

  Imagine you are a health care provider and one of your patients suffers a poor outcome. Now imagine what it feels like if you think that maybe you could have done something differently. Maybe things would have turned out differently.

  Maybe, in retrospect, you are second-guessing what you did or the decisions you made. Even worse, maybe you clearly made a mistake. Now imagine the worst-case scenario of all: your patient has died. Imagine what all the second-guessing must feel like. Imagine the weight of that on your mind.

  In intensive care medicine and emergency medicine—two of the fields with the highest physician burnout rates in all of medicine—health care providers feel this weight frequently. In these fields, health care providers often have to make split-second decisions based on limited information with someone’s life hanging in the balance. And they see the worst patient outcomes imaginable.

  Even the most knowledgeable and skilled clinicians find themselves with cases where, in retrospect, they wish they could turn back time and choose a different approach that just maybe could have saved a life. Imagine what that feels like to have tried and failed. Maybe there were forks in the road where if different decisions were made it could have changed things just enough to alter an outcome.

  The guilt and the pain weigh on the mind…and the soul. In struggling with the weight of that, health care providers can go to dark places: depression, anxiety, insomnia, nightmares, and even flashbacks. They can’t stop replaying these situations in their heads.

  Repeatedly, they beat themselves up over what they could have or should have done differently. If one was already suffering from burnout, a bad patient outcome (with a sense of a missed opportunity to make a difference) could be the thing that sends a health care provider “over the edge.”

  What do we tell a health care provider in the midst of this struggle? What should they be telling themselves?

  As Lama Yeshe, a Tibetan spiritual teacher advised, “Be gentle first with yourself if you wish to be gentle with others.” A similar approach is recommended by Dr. Kristin Neff, one of the world’s leading researchers on the topic of “self-compassion.”

  With self-compassion, we offer ourselves the same kindness and care we would offer to a good friend going through the same circumstances.428 A foundation of self-compassion is the recognition that failure and imperfection are part of the human condition.

  Dr. Neff further explains self-compassion this way:

  “Instead of mercilessly judging and criticizing yourself for various inadequacies or shortcomings, self-compassion means you are kind and understanding when confronted with personal failings—after all, who ever said you were supposed to be perfect?”429

  If you realize the importance of compassion for others in a time of personal failure, then when you are in need of that compassion yourself, you must make sure that your internal dialogue reflects the same encouragement and compassion you would show to others in your situation.

  Of course, when a bad patient outcome occurs, thoughtful introspection and accountability are important. But the quality of this internal dialogue is key. For far too many health care providers, the internal dialogue that they hear repeatedly is not the voice of understanding and compassion, but rather a horrible, berating voice that can lead to an overwhelming depression they cannot escape.

  In her book, Self-Compassion: The Proven Power of Being Kind to Yourself, Dr. Neff walks readers through the rigorous science behind self-compassion, and the evidence-based approaches to increase one’s self-compassion. But one simple way to think about it is this: When you are struggling with failure, what would your best friend say to you (or about you)? Does your internal dialogue match what your best friend would say?

  A poignant example of this comes from the work of psychology researcher Dr. James Kirby, who you were introduced to earlier in this chapter. Kirby relates a story of working with a 17-year-old male on self-compassion.430 Kirby asked this young man to consider scenarios where serious failure was experienced and then write down five things he would say to a friend going through that failure.

  Then, Kirby asked him to write down five things he would say to himself in that exact same failure. The results were startling:

  To a friend, this teenager said: “There’s always next time.” “They don’t deserve you.” “You’re only human.” “I’m stupid too.” “Don’t listen to them.”

  But to himself he said: “I’m a failure.” “No one likes me.” “I’m an idiot.” “I’m stupid.” “He’s right.”

  Kirby appropriately sums up the boy’s internal dialogue to himself in just one word: “Devastating.”

  Dr. Dennis Tirch, a renowned expert in compassion-focused therapy, describes self-compassion like this: “It isn’t about negating or rejecting undesirable thoughts like self-criticism or shame. It’s about extending validation, warmth and caring to them, and recognizing where they’re coming from. The same as we would do to
a friend who was suffering.”431

  In this chapter, you have seen the scientific evidence that compassion can be an antidote to burnout and a powerful promoter of resilience and one’s own well-being. But that was compassion for others. It is also vital to realize that another powerful promoter of resilience is treating yourself with the same compassion that you already know makes a meaningful difference in the treatment of others.

  Your internal dialogue must also be a voice of compassion—for yourself.

  When it comes to health care providers who struggle with the reality of a poor patient outcome, they often mercilessly beat themselves up over what they could have or should have done differently. This is fuel to the fire of burnout.

  If you find yourself in that moment…stop. Stop beating yourself up.

  Instead, remember this question: Is that what your best friend would say to you?

  Steve’s Story: A Life-Changing (n=1) Experiment432

  So this is where the science converges with the personal. A couple of years ago, after nearly twenty years of working in an ICU, and literally meeting people on the worst day of their lives, I came to a stark realization…I had almost every symptom of burnout.

  Let me assure you, it’s not a good place to be. It can be a dark place.