Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: And now, your host, Dr. Sergio Zanotti.
Speaker: May is a national critical care awareness and recognition month.
Speaker: During this month, we recognize many of our team members who make a difference for patients and families in our ICUs.
Speaker: To mark this special month, today's episode of Critical Matters will focus on the one thing that always makes a difference and is hold true for many, many years, and that is compassion in the ICU.
Speaker: We are very lucky and honored to have back Dr. Steven Trzyak as a guest for the podcast.
Speaker: Dr. Trzyak is Chief of Medicine at Cooper University Healthcare and Professor and Chair of Medicine at Cooper Medical School of Rowan University in Camden, New Jersey.
Speaker: Dr. Trzyak is a practicing intensivist and an NIH-funded clinical researcher with more than 100 publications in the scientific literature.
Speaker: His research interests include resuscitation, shock, cardiac arrest, and in recent years, the scientific study of compassion in medicine.
Speaker: He is the co-author of a recently published book, Compassionomics, The Revolutionary Scientific Evidence That Caring Makes a Difference.
Speaker: And today, he's back to talk about compassion.
Speaker: Steve, welcome back to Critical Matters.
Speaker: Sergio, thanks so much for having me on the podcast.
Speaker: It's great to be here, and I really appreciate it.
Speaker: So since we last spoke on critical matters over a year ago, a lot has happened in the field of compassionomics and with your team.
Speaker: You've published a phenomenal book that we will definitely link in the show notes and we'll talk about today.
Speaker: You've also had some very interesting original studies looking at compassion and its effect on patients and how to measure it.
Speaker: We'll also hopefully touch today.
Speaker: So really a busy year since we last spoke, Steve.
Speaker: It has been a busy year, and I think that the topic of compassion in medicine in general, just beyond the ICU, but in healthcare in general, really resonates with people.
Speaker: And the reason is that so many people have a story, either a story where a healthcare provider treated them with incredible compassion and it made a major difference in their life,
Speaker: or unfortunately on the other side of the scale, where they were treated with an absence of compassion and it made a lot of difference in the wrong direction.
Speaker: And so I think the topic is something that really resonates with people.
Speaker: And as you mentioned, we're also now trying to build the original science program to get to new discoveries in this space as well.
Speaker: And I think that you've mentioned it in Compassionomics, but a lot of people have talked about this in different ways.
Speaker: But at the end of the day, people don't remember what you said.
Speaker: They don't remember what you did.
Speaker: But they definitely remember how you made them feel.
Speaker: And I think especially in the ICU, when either people are very critical and at the verge of death or people lose loved ones, I think that is probably more true than anywhere else.
Speaker: Absolutely.
Speaker: And it stays with people.
Speaker: I mean, there's research to show that when you break bad news to patients or families, when you tell them the news that creates the worst day of their life, they'll never forget it.
Speaker: And they can remember every little detail.
Speaker: You as the health care provider may not remember the details even a month from that point, but they'll never forget it.
Speaker: In fact, they can give you such stark detail as they can tell you what's
Speaker: what you were wearing at the time they can picture it right in front of them like it was like it was yesterday so I would like to start
Speaker: for maybe a refresher for some of our listeners who may have heard the first episode we did together, but also to make sure that everybody's on the same page with some basic definitions, which I think will set up the stage for our discussion, Steve.
Speaker: I think a lot of people talk about empathy in medicine, compassion in medicine.
Speaker: Some people tend to confuse them, but could you start by defining the difference between empathy and compassion?
Speaker: Absolutely.
Speaker: So the terms are related to
Speaker: closely related actually, and yet distinct.
Speaker: So empathy is the feeling or understanding of one's emotions, and that includes the detection.
Speaker: So detecting, feeling, and understanding.
Speaker: Compassion is a bit different.
Speaker: So it's not just feeling or understanding, but the emotional, but in emotional response to take action to relieve another's pain or suffering.
Speaker: So compassion is typically defined as the emotional response to another's pain or suffering involving an authentic desire to help.
Speaker: So the way we try to illustrate the difference between the two is that empathy plus action equals compassion.
Speaker: But clearly empathy is vital because if you can't detect, feel, or understand another's emotions,
Speaker: you would never be motivated to take action to try to relieve someone's pain or suffering.
Speaker: So they're very closely related.
Speaker: Of course, you must have empathy in order to show compassion.
Speaker: But you could have empathy for someone and yet take no action and the patient would never know the difference.
Speaker: So my colleague, Anthony Mazzarelli, who's a co-author on the book Compassionomics, likes to say that you can have empathy through a one-way mirror, but you can't have compassion.
Speaker: And compassion is what the patient experiences in the actions that you take to try to help them.
Speaker: And I think that one of the concepts that I think has been most interesting for me since we started talking about these topics that you have brought to my attention and start thinking about it in a more rigorous way is also that when we talk about compassion, a lot of people feel the touchy-feely and a lot of people feel pain.
Speaker: But there's also a recognition that whatever makes me feel better makes another human being feel better.
Speaker: And that is also a compassionate in terms of our actions that
Speaker: recognizing that as I would feel other people would also feel if I do certain things and I think that's maybe a good guiding principle for us in the ICU not only with our patients but with our colleagues.
Speaker: I totally agree and I'm glad you brought up colleagues because relationships matter and so much of the book we've dedicated to relationships with patients or in the case of the ICU patients and families
Speaker: But relationships with each other among caregivers is also a vital component of the experiences that we have in taking care of people.
Speaker: And showing compassion for one another is also vitally important.
Speaker: What is compassionomics?
Speaker: So compassionomics is the convergence of the science and the art of medicine.
Speaker: So we often think of the science and the art of medicine as distinct.
Speaker: And it's
Speaker: compassion omics is the is an approach really so for decades voices in medicine and have been calling for more compassionate medicine as we we look back on decades I'm not certain that it's really moved the needle very much and so Anthony Mazzarelli and I decided that we needed to take a different approach and try to look for the scientific effects where the where is the evidence of
Speaker: that caring makes a difference, not only for patients and patient care, but also for those who care for patients.
Speaker: And so Compassionomics is our approach where we're trying to take, where possible, a quantitative approach, because what we have found in curating the evidence in the biomedical literature that have been published over the decades, what we have found is that compassion matters.
Speaker: not only in meaningful ways, but also in measurable ways.
Speaker: And there's no doubt that one ought to treat patients with compassion.
Speaker: It's axiomatic.
Speaker: It's the reason why most people go into healthcare is because they want to help people.
Speaker: And of course, there's a moral imperative to treat people with compassion, to treat people the way we would want to be treated ourselves.
Speaker: But does compassion really matter in the sense that is it just an ought?
Speaker: We ought to treat patients with compassion or are there also evidence-based effects belonging in the science of medicine?
Speaker: And what is the evidence?
Speaker: So in Compassionomics, we took a two-year journey through the literature and we curated all the evidence from the studies that have been published over the last several decades that
Speaker: ask the question, does compassion really matter?
Speaker: And once you see all the data compiled together in aggregate, it forms this unmistakable signal that compassion does matter in not only meaningful but also measurable ways.
Speaker: And once we saw it, it was hard to unsee that.
Speaker: It was a message that we felt that we need to carry forward and to spread as much as we could, so we decided to write a book about it.
Speaker: And I think that for those who have not read the book, I highly encourage.
Speaker: I found a tremendous wealth of information.
Speaker: And I think, like you say, Steve, a lot of things that we think we ought to do that we don't do.
Speaker: Now with this evidence, I think it gives it a much higher urgency in terms of something that we need to be more deliberate about.
Speaker: And we'll talk about this.
Speaker: what these effects are in a second.
Speaker: But before we go there, could you tell us kind of what does the evidence suggest in terms of the prevalence or the state of compassion in healthcare today?
Speaker: Sure.
Speaker: So of the 250 or so original science papers that are referenced in the book, we found an abundance of data that in healthcare,
Speaker: We are currently in the midst of a compassion crisis.
Speaker: And that's not to say that there's not compassion in medicine.
Speaker: Of course there is.
Speaker: There are striking stories every day in the ICUs and the hospital floors of every hospital in America.
Speaker: But are we consistent about it?
Speaker: And there is striking evidence that we don't.
Speaker: that were not consistent about it.
Speaker: So I'll just share with you some data.
Speaker: But first I want to tell you a story.
Speaker: So on February 26, 2007, a commuter bus packed with passengers collided head-on with another bus on a snowy highway outside of Uppsala, Sweden.
Speaker: one of the buses was literally sheared in half along the long axis.
Speaker: The wreckage was so bad and the extrication of passengers from the bus was so complex that the case actually made it into a disaster medicine textbook.
Speaker: So five years later, researchers asked the question, what do survivors remember?
Speaker: There were 56 survivors.
Speaker: Unfortunately, six people lost their life, but 56 people were saved.
Speaker: And five years later, using a rigorous qualitative research methodology, researchers interviewed every survivor and they found two common themes in what they remembered.
Speaker: There were two striking things that were imprinted on their brain.
Speaker: Number one was the physical pain that they felt at the moment of impact.
Speaker: And that was expected.
Speaker: But the other theme was a lack of
Speaker: of compassion from the caregivers at the hospital.
Speaker: But that's not the most striking thing.
Speaker: The most striking thing was when you realize that the patients were taken to three different trauma centers.
Speaker: They all had the same experience.
Speaker: So these data began to open my eyes to the fact that in healthcare, we have a compassion crisis.
Speaker: And so there is evidence from a health affairs study published
Speaker: by researchers from Harvard University found that nearly half of all Americans believe that the U.S. healthcare system and our healthcare providers are not compassionate.
Speaker: Another large-scale survey study found that two-thirds of Americans have had a meaningful healthcare experience with an absence of compassion.
Speaker: There's evidence that in the era of electronic health records,
Speaker: clinicians spend more time looking into computer screens and looking their patients in the eyes.
Speaker: And there's evidence that physicians miss between 60 and 90% of opportunities to respond to patients with compassion.
Speaker: Specifically within critical care, there was a Hopkins study from a few years back which measured every interaction between
Speaker: member of the healthcare team and patients or families in the ICU and found that 75% of all interactions had no expression of compassion between caregivers and patients and families.
Speaker: And one of the most striking studies that I'm aware of is a study from the University of Washington supported by a grant from the NIH published a number of years ago where they
Speaker: recorded every end-of-life conversation in the ICU and what they found using a rigorous methodology to code all the communication, they found that fully one-third of end-of-life discussions in the ICU had zero statements of compassion to families and patients.
Speaker: So when you put all that information together,
Speaker: I think that we are in the midst of a compassion crisis and I think it's being fueled really by, or I should say a marker of it, is that we're going through a burnout epidemic in healthcare.
Speaker: And one of the cornerstones of burnout is depersonalization, which is the inability to make a personal connection, which can make caregivers prone to callous or uncaring behavior.
Speaker: depersonalization and compassion are not opposites but if you have depersonalization then compassion is impossible if you can't make a personal connection and so putting all this together I think that we're in a state right now where where there is a lack of compassion and health care at least we're not consistent about providing it and I think that these obviously are very sobering findings and we've talked about it a
Speaker: offline multiple times and I've always thought that perhaps like many other things in life today, we are focusing on so many things in the ICU.
Speaker: So like this example of the bus collision, the trauma team was probably focusing on vital signs, bleeding, EKG, CT scans, and there's so much distractions that ultimately provide good outcomes.
Speaker: But we forget about the human being that is in that bed.
Speaker: And like you said, that's what ultimately stays with the survivors, which I think is very striking.
Speaker: Absolutely.
Speaker: The book obviously asks the question, does compassion matter?
Speaker: And the answer is yes, and we're going to dive into that a little bit more.
Speaker: But what I took home from reading the book, and I would like to hear your expertise in diving a little bit further, is kind of three big buckets.
Speaker: So when we think of value-driven healthcare, we always think about value as better patient outcomes and lower cost.
Speaker: And clearly, two of the big buckets that you have shown with Dr. Mazzarelli so nicely with all the review of the literature that are impacted tremendously by the presence of compassion are patient outcomes and the overall cost of health.
Speaker: So clearly, the more compassion, the better patients do.
Speaker: The more compassion, the lower the cost or the converse when there's a lack of compassion, costs seem to escalate very quickly.
Speaker: And the third bucket that I think you alluded to a little bit earlier has to do with the experience of the provider itself or the clinician.
Speaker: And in this,
Speaker: Increasing incidence of burnout, you have studies that also suggest or found studies that also suggest that compassion can be a way of mitigating or even avoiding burnout in physicians.
Speaker: So there's clearly a tremendous impact on the providers themselves.
Speaker: It is something that spiritual leaders such as Dalai Lama have talked about.
Speaker: many, many times that if you want somebody else to be happy, you are compassionate towards them.
Speaker: And if you really want to be happy yourself, you are compassionate towards other people.
Speaker: And that's the effect that I think you have also found in studies on providers.
Speaker: So why don't we dive into each one of these buckets, Stephen, start by talking about compassion and patient outcomes.
Speaker: Sure.
Speaker: So
Speaker: We like to think about mechanisms when we talk about impacting patients' health.
Speaker: So what are the mechanisms by which compassionate care can have beneficial effects for patients?
Speaker: So there are physiological effects, and we can talk about some of those.
Speaker: There are also psychological effects, which perhaps are not surprising that compassion for others can modulate their depression and anxiety and things like that.
Speaker: There are also...
Speaker: effects on health care quality, meaning the quality of care that's provided, and specifically the meticulousness of patient care.
Speaker: And then there's also patient self-care, so how well patients take care of themselves during all the time, the vast majority of the time, when they're not in front of their physician in the doctor's office.
Speaker: So all of these things can be areas where compassion can impact patients in meaningful ways.
Speaker: So, for example, physiologically.
Speaker: So there is data that compassion for others can modulate stress-mediated disease.
Speaker: There's also evidence that compassion for others can modulate a patient's perception of pain.
Speaker: So I didn't say eliminate pain, but can attenuate or reduce it to some extent.
Speaker: And that's been shown
Speaker: over and over again, not only in experimental settings, in laboratory settings of experimentally induced pain, but also in clinical settings.
Speaker: Compassion for others in human connection can modulate immune system effects or can have effects on the immune system.
Speaker: And there are also endocrine effects in patients with diabetes.
Speaker: numerous different categories in which compassion can have physiological effects for patients.
Speaker: One of the most interesting areas by which compassion can modulate health is in patient self-care.
Speaker: So years ago there was a study from Johns Hopkins of 1,300 patients with HIV, okay?
Speaker: And this study speaks to the importance of self-care and how human connection between a caregiver and a patient can have a major impact on self-care.
Speaker: So they asked these 1,300 patients with HIV, does your doctor know you as a person?
Speaker: And the outcome measure for this study, or one of them, was adherence to antirithroviral therapy.
Speaker: So of course,
Speaker: HIV is a disease that in 2019 is controllable, but it is vitally important that patients take their medicine.
Speaker: So does human connection and the relationships with healthcare providers change adherence to therapy and have a beneficial effect on self-care?
Speaker: In this Hopkins study of 1,300 patients with HIV, they measured everything that was associated with adherence versus non-adherence,
Speaker: And they had a very rigorous way of analyzing the data to adjust for all those things.
Speaker: And what they found was that the answer to the question, does your healthcare provider know you as a person?
Speaker: If the answer was yes, it was associated with a higher belief, patients, what they call self-efficacy, meaning the patient was more likely to believe that the medicine could actually control their disease.
Speaker: It was also associated with a 33% higher odds of actually adhering to antiretroviral therapy.
Speaker: But then the most striking finding was that it was associated with a 20% higher odds of having no detectable virus in the blood.
Speaker: So this is after adjustment for all of the things that would be associated with adherence.
Speaker: What they found was knowing the patient as a person was associated with
Speaker: The patient believing the therapy would work, the patient actually taking the medicine, and then having a viral clearance of the virus from the blood.
Speaker: So I think that's really striking evidence that human connection can affect health in powerful ways.
Speaker: And I think that one of the outcomes that we always focus on in critical care is mortality or organ failure.
Speaker: So very short-sighted in terms of immediate outcomes that we control in the ICU, but there's a growing body of evidence that
Speaker: that ultimately for patients who survive, there are many, many other things that matter that really stick with them for months to come, even years, ranging from cognitive dysfunction to physical impairment to difficulties at their jobs, but also important incidents found in critical illness survivors of PTSD or post-traumatic stress disorder.
Speaker: I know that you recently have published with your group a very interesting
Speaker: paper in intensive care medicine on the impact of healthcare compassion in the ED on findings of PTSD a month later in these patients who have a life-threatening event.
Speaker: Could you talk a little bit about that, Steve?
Speaker: Sure.
Speaker: And that's a perfect segue into the psychological effects of compassion.
Speaker: So I had mentioned depression and anxiety, and there are tons.
Speaker: There's abundant evidence that compassion from healthcare providers, whether they're psychiatrists, psychologists,
Speaker: oncologists that compassion for patients can affect one's mental health in meaningful ways, both in the disorders I mentioned, but also in just the emotional effects of somatic illness, like receiving a cancer diagnosis.
Speaker: So there's no doubt that compassion from one person to another can have important psychological effects, and that's probably intuitive to some extent.
Speaker: But we wanted to test the hypothesis in an emergency context.
Speaker: And so that's when I collaborated with our science director here at Cooper.
Speaker: His name's Brian Roberts.
Speaker: He's an accomplished scientist and NIH-funded clinical researcher from the Department of Emergency Medicine here at Cooper.
Speaker: And Brian and I work together and continue to work together in testing a hypothesis
Speaker: that compassion from caregivers when a patient is in the throes of a life-threatening emergency can impact long-term psychological outcome.
Speaker: And the way in which we started to study this is I was collaborating with Brian in cardiac arrest research for a number of years.
Speaker: And what Brian was finding in doing follow-up
Speaker: evaluations of the survivors that we had months down the road is that many of them were just not right.
Speaker: And what we mean by that is they were having a very hard time with adjustment to their new health condition.
Speaker: And now, in retrospect, we recognize that also many of these patients were suffering symptoms of PTSD.
Speaker: And as you mentioned, it's now well known that 25% to one third of patients who go through life-threatening critical illness come out with PTSD symptoms on the back end of survivorship.
Speaker: And what we also found is that this is not only true for people who are in the ICU, but some of the psychological trauma
Speaker: can be occurring before patients even reach the ICU.
Speaker: So imagine being a patient with life-threatening respiratory distress or cardiovascular instability and you're brought into the emergency department and you're on a stretcher in the emergency department with caregivers scrambling all around you trying to save your life.
Speaker: And you might hear people say things like, he's trying to die on us, or they're circling the drain, or things like this that must just be unbelievably terrifying for people.
Speaker: So what Brian found in his work and was in our paper just recently published in Intensive Care Medicine,
Speaker: was that 25% of patients that come to the emergency department in this pilot study of 100 patients who presented to the emergency department with life-threatening medical emergency, 25% made diagnostic criteria for PTSD at 30 days.
Speaker: And the hypothesis that we tested was that
Speaker: compassion for patients at the point of care in the emergency department during the life-threatening emergency as judged by the patient just prior or at the conclusion of their ED phase of therapy was associated with lower incidence of PTSD at 30 days.
Speaker: And the proposed mechanism there is something called perceived threat.
Speaker: which is a term from the PTSD literature in which a patient has to perceive a life threat in order to suffer the psychological trauma and end up with PTSD.
Speaker: So the notion here is that rather than treating PTSD after it's already set in and developed,
Speaker: if you can intervene in such a way at the point of care to reduce perceived threat on part of the patient, then you can actually prevent the psychological trauma rather than trying to treat it later on after it's already occurred.
Speaker: And so this is currently, this is a pilot study.
Speaker: Brian is now just in the process of submitting
Speaker: and a grant to the NIH to do a follow-up study of this.
Speaker: But we're encouraged by the results because it suggests a new paradigm or way of thinking about PTSD from critical illness.
Speaker: Maybe we can actually prevent psychological trauma rather than just reacting to it after we're looking at the sequela.
Speaker: And I think it really speaks very powerfully to what we usually have learned in other diseases that time-sensitive interventions
Speaker: have a tremendous effect downstream maybe a month later.
Speaker: And this is no different, it seems like.
Speaker: I mean, at the right time, an early intervention being compassion really has a powerful effect that can be measured a month later.
Speaker: That's the approach that we're taking, and that's the way we're thinking about it.
Speaker: Early interventions matter, and we think that the same thing might be true for compassion and PTSD.
Speaker: We just haven't tested the hypothesis yet.
Speaker: So that's one of our next steps.
Speaker: So more to come, and we definitely will talk about it as you conclude these studies.
Speaker: So I think that in today's healthcare, cost is an often neglected aspect of value.
Speaker: I think that as clinicians, we haven't been good stewards in many occasions, especially in the ICU, of eliminating waste.
Speaker: But I think that even though payers demand higher value,
Speaker: Ultimately, providing value is most important for patients and for society.
Speaker: And I think that that is doing both parts of this equation, which is not only improving outcomes, but also making sure that we are good stewards of the resources, which are limited, and utilize them in the right way.
Speaker: So from a cost perspective, Steve, could you tell us some of the literature in terms of what happens when there's a lack of compassion in care?
Speaker: Sure.
Speaker: There are a couple things that I would point to.
Speaker: One is in the context of primary care, for example.
Speaker: So discretionary resource use and human connection between the caregiver and the patient has been studied.
Speaker: And actually, we found four different studies in the primary care literature to support this, and we describe them in the book.
Speaker: And they all found the same thing.
Speaker: And what they found was that compassionate, patient-centered care was associated with lower discretionary resource use by physicians.
Speaker: So fewer diagnostic tests, presumably some of those unnecessary diagnostic tests, fewer unnecessary admissions to the hospital, fewer unnecessary referrals to specialists,
Speaker: and lower total healthcare charges.
Speaker: So the authors don't posit a reason for that, they just note the association.
Speaker: I think one of the possibilities is that if you have a personal connection and a strong doctor-patient relationship with patients, you might not need all the tests and referrals and the quote, high-tech solutions
Speaker: that people do rely on when they don't have a good relationship with their patients.
Speaker: Sometimes it's just easier to order another test or refer a patient to see a specialist when actually all it may require to allay the patient's fears is to have a good talk with them.
Speaker: And the last bucket that we talked about, which I think is also very important, relates to clinicians and clinicians' burnout.
Speaker: So I think that many of us have observed that it… Can we go back?
Speaker: Yes, please.
Speaker: Yeah, one other thing I wanted to mention with respect to costs is medical errors.
Speaker: So there is a clear signal in the data, and I'm not going to suggest to you that it's causation because…
Speaker: we can't possibly infer causation from the available data.
Speaker: But it's the association between compassion for patients and medical errors.
Speaker: So the data in this area comes from the burnout literature.
Speaker: And so one of the things I mentioned earlier is that
Speaker: one of the cornerstones of burnout is depersonalization.
Speaker: So the three components of burnout are depersonalization, emotional exhaustion, and the feeling that you can't make a difference.
Speaker: So depersonalization is not the opposite of compassion, but if you have depersonalization, an inability to make a personal connection, there's no way that compassion can exist.
Speaker: So there is an abundance of evidence in the biomedical literature
Speaker: that depersonalization on the part of healthcare providers toward patients is associated with more errors.
Speaker: That has been shown in numerous studies.
Speaker: It's been shown in trainees.
Speaker: It's been shown in surgeons as well.
Speaker: So not just medical physicians where higher depersonalization is associated with more major medical errors,
Speaker: but also depersonalization on the part of surgeons has been associated with three times higher incidence of self-reported major surgical errors.
Speaker: And the main reason that the surgeons attributed, or to what they attributed the error, was a lapse in judgment.
Speaker: So I think it might be intuitive to many people that
Speaker: If you care more about the caring part of healthcare, you might also be more meticulous and put more attention to detail.
Speaker: Some of us have been exposed to colleagues who we thought they just didn't care and really didn't care about patients, and maybe we thought they were a bit sloppy in how they take care of patients as a result.
Speaker: So I'm not suggesting to you that depersonalization
Speaker: or a lack of compassion is causing the errors, but they do appear to go in the same direction.
Speaker: And I think that there's good evidence that they're associated.
Speaker: And of course, meticulousness and attention to detail is one of the pillars of critical care because it's all about the details.
Speaker: So being as meticulous as possible, I think, goes with caring deeply about patients and the outcomes that they experience.
Speaker: So the reason why I raised this in the part of the discussion about costs is because medical errors are not only of profound importance to patients for all the human toll that occur from them, but there's also a huge economic toll for medical errors as well.
Speaker: And so if we have more caring,
Speaker: perhaps will have more meticulousness, perhaps will have slightly fewer errors and just a small impact on errors given the magnitude of what they represent to the healthcare system in terms of cost, it would be a big number indeed.
Speaker: And it's very interesting, Steve, in terms of the whole concept of the extreme of burnout and depersonalization that I think that
Speaker: A very important element of compassion is recognizing
Speaker: other human beings what we recognize in ourselves right so the patient sure somebody's husband is somebody's father is somebody's son the same way that we feel ourselves in that respect but a very interesting study that I read many years ago and really never made the connection to all this until recently was a study where they they they tested a series of of
Speaker: CT scans, I think it was, with a large radiology group.
Speaker: And basically, with such a volume, they could pass these CT scans over a separate time of period.
Speaker: But the difference was, the radiologists were the same, but the difference was that in one group, they had a
Speaker: Basically, they just looked at the CAT scans and they reported the findings.
Speaker: And then several months later, they passed all the same CAT scans again.
Speaker: But now each patient had a photograph and a little blurb of the person.
Speaker: And the number of incidental findings and the number of things missed was significantly different when the radiologist connected the CAT scan to an individual.
Speaker: And it's very interesting, I think, that it maybe speaks to a lot of things that you were talking about earlier, but there might be other things or other mechanisms that we don't recognize yet.
Speaker: Absolutely.
Speaker: I think that the paper that you reference is just a pointed example of how much human connection and caring for people, not just for CAT scans, really can help.
Speaker: can change behavior and motivate people to go the extra mile, so to speak.
Speaker: So a lot of times I joke that in community practice, we recognize things empirically that ultimately science finds very fancy ways to prove to us in large numbers.
Speaker: And one of the things that I think I have recognized in my own practice, you have recognized because we've talked about it and many others have,
Speaker: is that if you're having a bad day, one of the most efficient ways to make it a better day is to go down and maybe choose the most difficult family or the sickest patient, go to that room and sit down with the family or with the patient and give them your time and talk about what's going on, what are things that we can and can't do, and really show compassion towards that patient or that family.
Speaker: You have talked about in the book about the impact of compassion on physician burnout and the prevalence of burnout being so high and being a very worrisome problem.
Speaker: Could you share with us a little bit more details about what the literature tells us in this respect?
Speaker: Absolutely.
Speaker: So I recall when I was a medical student,
Speaker: I was taught, and of course this was part of the hidden curriculum, not really the overt curriculum, but I remember being taught by a senior resident physician, don't get too close to patients because if you do, that'll just put you at risk for burnout.
Speaker: Too much caring, too much compassion will burn you out.
Speaker: Since sharing this story, I've encountered a number of people that heard the exact same message at some point along their training.
Speaker: And in writing the book, Compassionomics, we went through all the literature on this.
Speaker: And we actually can't find any data to support that.
Speaker: So for example, if there were data
Speaker: to support that hypothesis that too much compassion or too much caring and connection would burn you out, then everywhere it had been studied in the medical literature, we would see an association with compassion and burnout going in the same direction.
Speaker: So high compassion, high burnout.
Speaker: Low compassion, low burnout.
Speaker: And actually, when you look at the available evidence in the biomedical literature,
Speaker: it actually shows the opposite.
Speaker: So the majority, the vast majority of published studies have found in fact a significant association between compassion and burnout.
Speaker: But what they find is that it's an inverse relationship.
Speaker: So high compassion, low burnout, low compassion, high burnout.
Speaker: Now some might jump to the conclusion or try to infer causation from that in a certain direction to say burnout
Speaker: crushes compassion.
Speaker: But actually, when you look at the data, there is a wealth of information in the biomedical literature that actually suggests the opposite, that it might be the people with the lowest compassion that are the most predisposed to developing burnout under the same amount of stress.
Speaker: And a mechanism by which that can be true is that it's the relationships that matter.
Speaker: So it's the positive relationship with patients or patients and families that give medicine, they give you the fulfillment of taking care of patients and provide a fulfilling, positive experience that build resilience.
Speaker: So it's people who can't make that connection that are the highest risk for burnout.
Speaker: And
Speaker: then by extension, it might be that having better relationships with patients makes you lower risk for developing burnout or could even treat burnout if you're already suffering from it.
Speaker: And I think that this is obviously something that requires a lot more discussion, the whole concept of burnout and the whole balance between environmental factors, intrinsic factors to the provider.
Speaker: But I think that both of us empirically have recognized that being deliberate about compassion does help you feel better and does help you find purpose and mitigate the effects of burnout in the ICU.
Speaker: Would that be fair to say?
Speaker: Absolutely.
Speaker: I mean, I went through it myself, to be honest.
Speaker: So this is sort of where the science meets the personal.
Speaker: So after about 20 years of, almost 20 years of working in an ICU, and what we do for a living, basically, is we meet people on the worst day of their life, right?
Speaker: So after almost 20 years of doing that, I came to the stark realization that I had almost every symptom of burnout and me personally.
Speaker: And that is definitely not a good place to be.
Speaker: So what was I supposed to do?
Speaker: Well, I did, what I did is, my go-to is to go to the data.
Speaker: So I'm a research nerd by background, right?
Speaker: So I went to the data and I looked in the literature and
Speaker: I tried to answer the question, what next?
Speaker: What do we do now?
Speaker: And everything that I found was not very appealing to me.
Speaker: So there were approaches to treating burnout that I consider to be escapism.
Speaker: And what I mean by that is get away more, detach, go on vacation, go on nature hikes, just get away.
Speaker: As if, if you're burned out, all you have to do is spend as much time as possible away from patients and everything will be okay.
Speaker: And I think that's probably a little bit naive.
Speaker: I do believe in work-life balance.
Speaker: There's no doubt about that.
Speaker: That's completely, that's vital, no doubt about it.
Speaker: But I thought that the antidote to burnout had to be at the point of care with the patient.
Speaker: And so,
Speaker: when I was newly armed with all this evidence that compassion for patients was associated with lower burnout, I decided to test that compassion hypothesis for myself.
Speaker: And I decided to try to care more rather than less and build stronger relationships with my patients and families rather than fewer or less relationships.
Speaker: And for me, that's when everything began to change.
Speaker: And I felt that burnout was beginning to lift.
Speaker: And so there's data behind it.
Speaker: It's not experimental data, but if you look at the cross-sectional studies,
Speaker: Burnout and compassion are inversely related.
Speaker: And so I tested the compassion hypothesis for myself, and it was really powerful.
Speaker: And anybody out there listening that is going through burnout themselves, I would suggest that you test that compassion hypothesis for yourself and see what happens.
Speaker: So I just have to say, Steve, that having been a close friend of yours for many, many years, the point that does not escape for a second for me and is very interesting to not say ironic is that for being such a data-driven nerd like you self-describe yourself, which I think is an understatement, it is fascinating that the study with an N of one has really changed the path of your research endeavors.
Speaker: Well, it's actually all the studies that were already in the literature.
Speaker: I just applied it to my N of 1.
Speaker: So it had plenty of scientific rigor, Sergio.
Speaker: I know.
Speaker: But I have to give you that punch there.
Speaker: But I do think that it's something that we'll talk a little bit more towards the end.
Speaker: But the one thing I wanted to ask you, Stephen, this, I think, speaks to a paper that you published very recently, this month, actually, in JAMA Open Source.
Speaker: It relates to this whole concept that we have a crisis.
Speaker: You want to change behaviors.
Speaker: But if you can't measure a process, you can't manage it.
Speaker: So how do we measure compassion in clinicians?
Speaker: Yeah, it's a really important question because we wanted to take and want to take going forward as we develop the original science research program with Compassionomics.
Speaker: We want to be as rigorous as possible.
Speaker: And so, of course, we need to be able to measure compassion.
Speaker: And there have been ways to measure compassion.
Speaker: Many of them have been from
Speaker: the healthcare provider perspective, so like self-assessment of compassion, and no disrespect to investigators that have gone that direction, but there's plenty of data to show that healthcare providers, especially physicians, sometimes have a blind spot with respect to their own compassion, where they may think that they're the most compassionate doctor and patients don't necessarily agree.
Speaker: So for that reason, we thought that the only
Speaker: we thought that the best way to measure compassion is from the patient's perspective because ultimately it's all about the patient, it's all about what they're experiencing.
Speaker: So we set about to develop and validate a tool to measure patient assessment of compassion from the patient's perspective.
Speaker: We're actually working on validating this in other contexts as well.
Speaker: But this is a study of 6,000 patients who received care in an outpatient office setting.
Speaker: And so we found, after vetting a number of candidate items, questions that could be asked patients about the compassion of their caregivers, and we did all the psychometric testing on these candidate items, and ultimately ended up with five questions
Speaker: that can allow us now to measure compassion from the patient perspective at scale.
Speaker: So we actually derived and validated this in the context of what's called the CG-CAPS patient experience survey.
Speaker: So like if you go to a doctor's office and you get a survey in the mail, that's probably a CG-CAPS survey, which was developed by AHRQ and is...
Speaker: promoted by the Centers for Medicare and Medicaid Services.
Speaker: So this is the framework by which patient experience is measured in the U.S. in large part.
Speaker: And so we found that five questions, additional questions, that are related to how well healthcare providers communicate, but they're also distinct because they're not clarity of communication questions, they're caring questions.
Speaker: And what we found is that the statistics were excellent in terms of internal reliability and validation for these questions.
Speaker: So the questions are this.
Speaker: How often do you feel your provider cares about your emotional or psychological well-being?
Speaker: Do you feel your provider is interested in you as a whole person?
Speaker: Do you feel your provider is considerate of your personal needs?
Speaker: Do you feel your provider is able to gain your trust
Speaker: and you feel your provider shows you care and compassion.
Speaker: And so we developed and validated this as a tool going forward so that we can measure compassion at scale in healthcare organizations.
Speaker: And we thought that that was an important step forward, not just for the research and for the methodology, but also for taking care of patients, because we think that these
Speaker: our important readout from the patient perspective of how much they think we care.
Speaker: And I have a question, Steve, on this set of five questions.
Speaker: I read the paper and I really found it very interesting.
Speaker: But my question was, how did question five
Speaker: How often do you feel your provider shows you care and compassion function just as by itself?
Speaker: It feels that a lot of the questions might discern specific aspects of the interaction, but that kind of almost encapsulates it, right?
Speaker: Because that's ultimately what you want the patient to feel or not feel, I guess.
Speaker: I agree intuitively until you do the psychometric testing on it.
Speaker: And this, again, was a study led by Brian Roberts, who's our science director in our research program.
Speaker: But we started with 12 candidate questions that we derived from a systematic review of the literature, which extracted all the questions that have been used in prior ways to measure compassionate care from the patient perspective.
Speaker: And then we disseminated all those questions.
Speaker: We ultimately landed on these five questions because what we found is if you take any one of these five questions out, the statistics on the reliability of the measure goes down significantly.
Speaker: So we actually find that I would have hypothesized the same thing that you did that really you only need to ask that one question.
Speaker: But what the data showed is that all five of these questions about knowing you as a whole person, trust, emotional and psychological needs, all these things are vital for having a very rigorous measure from a scientific perspective and all the psychometric testing that's involved with that.
Speaker: So definitely, I think we'll follow with a lot of interest.
Speaker: I mean, how this evolves and eventually, I guess, finding out what the best way of measuring this in the ICU is.
Speaker: But I think it leads us to the closing part of our conversation, Steve, for today, which is the whole question is compassionate product of nature or of nurture.
Speaker: And I think that ultimately a lot of people believe that they're born the way they're wired and that they're not touchy-feely.
Speaker: So this is not something they can do.
Speaker: And on the contrary, I think that what Compassionomics shows is that there is tremendous potential for all of us to be more compassionate.
Speaker: But I'll let you tell us a little bit more about that.
Speaker: Sure, so your listeners might think that because you invited me to come on in your show and talk about compassion that I must be the most compassionate doctor.
Speaker: But the truth is that I'm just a work in progress.
Speaker: But I see it now, having gone through 250 original science research papers, more than 1,000 scientific abstracts, and curating all the data and
Speaker: that appears in Compassionomics, I see quite clearly now that compassion for patients, compassionate behaviors, can in fact be learned.
Speaker: And that is good news indeed.
Speaker: That's good news for me.
Speaker: It shows that science shows that I can in fact get better.
Speaker: And once you realize that you can get better,
Speaker: then you're more likely to do so.
Speaker: And that's actually been shown in a number of studies, including Carol Dweck and colleagues from Stanford who did all the research on growth mindset in education.
Speaker: The belief that you can grow and get better at something, you don't perceive all of your
Speaker: limitations as failures, you see them as opportunities to get better.
Speaker: And their group has also studied compassion and has found that if you believe compassion is something you can get better at, you're more likely to work hard at it and actually get better.
Speaker: The operative word though is behaviors because that's what patients feel.
Speaker: They feel your behaviors.
Speaker: We're not talking about getting more compassion in your mind or what you think in your mind, but
Speaker: in terms of how you behave towards patients, there is an abundance of data that compassionate behaviors can in fact be learned.
Speaker: And I think that ultimately, obviously, that is the real challenge, right?
Speaker: I mean, we talked about how this is really important work for medicine, for patients, for providers.
Speaker: But ultimately, what we want to get to the path is how can we move the needle and help our colleagues and ourselves become more compassionate so that we can really have the right behaviors that make a difference for patients.
Speaker: Now, I know that you're a stickler for evidence, but I'm going to need your expert opinion here, Steve.
Speaker: And I would like to hear Dr. Tresiak's top three or five interventions or behaviors that we can implement to start being more compassionate with our patients.
Speaker: Sure.
Speaker: So the first one has to do with time.
Speaker: So a recent study from Harvard showed that 56% of physicians believed that they don't have time to be compassionate.
Speaker: So that begs the question, how much time does it actually take?
Speaker: Well, we found five different studies in our work with Compassionomics, which all show that it takes under a minute to have a meaningful connection with a patient and to communicate to patients that you care about them.
Speaker: It takes less than a minute, and that's been shown in a number of studies.
Speaker: So why is it that we think that we don't have enough time?
Speaker: One of these reasons is there's a terminology called time affluency, or time affluency meaning you feel like you have plenty of time, you're not in a hurry, versus I'm in a hurry, I don't have time for that.
Speaker: So this has been studied by investigators from Wharton who have found that there's only one type of ways, only one way of spending your time
Speaker: that actually increases your feeling of time affluency.
Speaker: Your feeling that you have plenty of time, that you're not in a hurry.
Speaker: And the only way, the only use of your time that increases that feeling is spending your time on other people.
Speaker: So 56% of physicians believe that they don't have time for compassion.
Speaker: Research shows that it takes less than a minute
Speaker: And research shows that if you do it, you're likely to feel that you actually have more time.
Speaker: So I guess my number one would be to think differently about our time, to realize that when we don't have enough time to show compassion to patients, it's probably all in our head.
Speaker: We actually probably do.
Speaker: And if we do it, it'll make us feel better about the time that we have.
Speaker: So that's number one.
Speaker: Number two is...
Speaker: indirectly related to patients, but really important.
Speaker: And that is compassion for each other as colleagues, because that creates the culture of compassion or a culture of a lack of compassion that we have in healthcare.
Speaker: And that affects patients in really powerful ways.
Speaker: there have been a number of studies on the culture of compassion in a healthcare environment and how that's associated with not only better outcomes for employees, healthcare providers, and sick days and employee experience, but also patient outcomes and patient experience as well.
Speaker: So the culture of your healthcare environment is
Speaker: super important.
Speaker: One thing that I have learned in my year and a half of being the chair of medicine at Cooper is that, you know, I get a lot of referrals to talk to people when things aren't going right for them.
Speaker: You know, their behavior is not right.
Speaker: They've had maybe some harsh interactions with patients or with families or they're
Speaker: they're just maybe a track record of great performance has suddenly become derailed for some reason.
Speaker: And I have the opportunity to meet with colleagues and to have one-on-one discussions with them when the door is shut.
Speaker: And what I have found, probably my most powerful lesson in Compassionomics over the last two years is this.
Speaker: you in general have no idea what kind of pain people are carrying around.
Speaker: So you might notice that one of your colleagues isn't just right, but you have no idea what kind of pain people are carrying around.
Speaker: And treating each other with compassion when it's needed and consistently
Speaker: is as vital to what we do in healthcare as how we directly treat the patients, because it creates the culture.
Speaker: But caring for each other is incredibly important, and that's a lesson that I've learned over the last year or two, and it's a lesson that I continue to learn every day.
Speaker: So compassion for each other is super important.
Speaker: The last thing I will tell you is directly related to
Speaker: to critical care.
Speaker: And oftentimes in critical care, we might say something to colleagues like, well, there's nothing we can do, or nothing can be done for this, when there is a uniformly fatal diagnosis or something like that.
Speaker: And while it's true that sometimes compassion can't make a difference
Speaker: in changing the reality of an outcome that's inevitable, it can still make a difference.
Speaker: What I mean by that is that when patients and families go through the worst day of their life, I said this at the beginning of the podcast, but it's something they'll never forget.
Speaker: And it's often described as an echo chamber.
Speaker: where they keep reliving it over and over and over again.
Speaker: In fact, my co-author Anthony Mazzarelli tells an especially poignant story of this at the end of the book in Compassionomics.
Speaker: And what I just want to leave people with is that patients and families will be revisited over and over again by
Speaker: some of the horrors that happened to them when they're going through the experience of critical illness.
Speaker: And in those moments when they are revisited by those thoughts, they can either be met with no compassion or every time they think of it, they can be revisited by the compassion that you showed them in the moment.
Speaker: And it can play in their mind over and over and over and over again.
Speaker: And so there's no p-value you can put on that.
Speaker: There's no confidence interval that you can put on that.
Speaker: There's no statistics that you can put on that.
Speaker: But that is an outcome.
Speaker: That is an experience of compassion in human connection that will be experienced over and over and over again.
Speaker: And that is extremely powerful.
Speaker: And my co-author told the story of that in the book.
Speaker: Patients and families have told me that over the almost 20 years that I've been practicing critical care, but that's really powerful.
Speaker: So even, I guess the last thing that I would say is that even when compassion can't make a difference, it still makes a difference.
Speaker: It always matters.
Speaker: And I think that those three are great pieces of advice.
Speaker: So to recap, I mean, time is always present.
Speaker: We always have the time to make a difference and you're right, Steve.
Speaker: The book talks about Dr. Weiner, Edward Weiner, who is somebody that we both had as a chair of medicine and I think we both agree is a phenomenal bedside clinician.
Speaker: And one of the tricks that he taught me that I've always incorporated is when you walk into a room and there's a family and you're gonna talk to them, sit down.
Speaker: And it doesn't take more time, but it just slows down the whole interaction
Speaker: And I think it really probably gives us that time of fluency, of giving them the right time without changing what happens in our day, but making a true difference.
Speaker: With regards to the compassion towards colleagues, I agree 100%.
Speaker: I think that as a CMO of a large group, I have a chance to speak with a lot of people, and I agree with you 100%.
Speaker: You never know what's going on.
Speaker: We're very quick to judging people in terms of their performance and putting labels, but you never know what's going on, and that's important.
Speaker: And finally, I think that the third point you make on understanding that perhaps
Speaker: When we can't make a true difference in outcomes, that's when compassion has the strongest impact and it should always be present.
Speaker: So I think that this is a great place to stop, Steve.
Speaker: I really enjoy the conversation.
Speaker: I look forward to...
Speaker: to what your group is producing.
Speaker: I do think this is a very important topic and I hope that we can find a way to scale it to many, many bedsides within Sound Physicians.
Speaker: But I do want to finish, as we usually do the podcast, with a couple of questions not related to this topic in particular.
Speaker: And you've been through this before, so the question will be a little bit different.
Speaker: Is that okay?
Speaker: Sure.
Speaker: So in some of our recent conversations, we started talking about music.
Speaker: So we talked about books and clearly the book associated to this episode is going to be Compassionomics and that will be linked in the show notes.
Speaker: But if you were on a desert island or you can only have one album in your office, what would it be?
Speaker: Well, that's a tough one.
Speaker: So if you go back historically, I would have to say U2, The Joshua Tree.
Speaker: So I don't pull it out all that often, but when I do and I hear the start of Where the Streets Have No Name, I'm instantly back to age 17 when I saw them in the best concert of my life.
Speaker: The other album, though, I will tell you,
Speaker: and this is through some exceptional mentoring by a jazz aficionado that I know, and I listen to more than just about any other album these days, is Keith Jarrett, The Cologne Concert.
Speaker: Have you ever heard of that?
Speaker: I have, and it is a phenomenal album.
Speaker: I was hoping you would say that, so we'll put that in the show notes.
Speaker: Well, it was a good recommendation from you and has become one of my all-time favorites.
Speaker: And it's a very special piece of music because of the circumstances in which was created, which we won't go into in the podcast today, but people can Google for themselves.
Speaker: And the last question that I have for you, Steve, is about failure.
Speaker: I think that society in general is very fearful of failure.
Speaker: And you talked about Carol Dweck, but the whole idea of a fixed mindset is really one that's averse to failure versus a growth mindset that really just wants to learn.
Speaker: But I believe that failure should be embraced because there's probably a lot more we can learn from failure than from success.
Speaker: So my last question is, could you share with us a really, really good failure that taught you something powerful?
Speaker: Well, I'm an expert in failure, Sergio.
Speaker: So it's hard to pick one when you have so many.
Speaker: But I think the first thing that pops into my mind is...
Speaker: a failure to appreciate the obvious.
Speaker: Okay?
Speaker: So one of the most interesting studies I've ever read in my life, many incredible scientific findings over the decades from, it comes from the Harvard study of adult development.
Speaker: So this was a study that occurred, it's more than 80 years old now.
Speaker: And
Speaker: what they did is they enrolled college kids.
Speaker: They were all men at the time because at that time Harvard only had male students.
Speaker: And they followed them over time.
Speaker: And what they wanted to do was what was the secret to longevity?
Speaker: So what could you measure at an early stage in life that would ultimately be most closely associated with good health much later in life?
Speaker: And what they found in a striking way, it wasn't their...
Speaker: achievements or their accolades.
Speaker: And it wasn't other middle-aged health outcomes that you might think wasn't their cholesterol level at age 50 that predicted their longevity and good health at age 80.
Speaker: It was one thing.
Speaker: It was the relationships that they had.
Speaker: So human connection is powerful in so many different ways.
Speaker: It even seems to be the secret to good health and longevity.
Speaker: I realize that now, right?
Speaker: And earlier on in my career, I think I was maybe more focused on
Speaker: getting the next grant out the door or trying to get papers published in really good journals.
Speaker: And now in retrospect, I wish I would have taken time to and invested that time in the relationships with those around me and my colleagues.
Speaker: And now I'm just trying to, now that I know better, now that I
Speaker: Now that I have realized that, I'm doing all I can to make up for that.
Speaker: And the science is really clear that human connection is really the secret to a lot of things that underlies our health.
Speaker: And the beauty about that failure in realization is that, as they say, the best time to plant a tree was 20 years ago.
Speaker: The second best time is today, right?
Speaker: So I think that there's always opportunity to move forward.
Speaker: Well, Steve, always a pleasure.
Speaker: This is a fascinating topic.
Speaker: I hope that we can have you back as you have more findings and we continue to evolve.
Speaker: And like I said, I mean, I hope that we can find a way to make sure that many, many bedsides find the compassion and make a difference for the careers of our colleagues.
Speaker: Thank you so much for your time.
Speaker: And thank you so much for sharing your expertise with us.
Speaker: Thank you, Sergio.
Speaker: Thanks again for listening to Critical Matters.
Speaker: Make sure to subscribe to this podcast on iTunes or Google Play.
Speaker: You can also listen at www.soundphysicians.com backslash podcast.
