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: What do you consider the most important topic to be researched in critical care medicine today?
Speaker: The one thing that if we got right would make a true difference for our patients no matter where they were.
Speaker: That was a very difficult question to answer and one that our guest
Speaker: thought about for some time and came to the conclusion that perhaps the answer was compassion, understanding compassion in the intensive care unit and how we could help others become more compassionate.
Speaker: It's a great pleasure to have back Dr. Steven Treziak
Speaker: who is professor of medicine and of emergency medicine at Cooper Medical School of Rowan University.
Speaker: He is also the physician business leader of the Adult Health Institute at Cooper University Healthcare in Camden, New Jersey.
Speaker: Dr. Trzyak is a practicing intensivist and prolific researcher.
Speaker: His research interests have included early interventions for critical illness and the interface between the ED and the ICU, with a heavy emphasis in septic shock and cardiac arrest.
Speaker: More recently, after pondering this question, Dr. Trijak's research has explored the impact of compassion on patient outcomes, healthcare economics, and physician well-being.
Speaker: Today, that will be our topic.
Speaker: Steve, welcome back to the podcast.
Speaker: A pleasure to have you here.
Speaker: Sergio, thanks so much for having me.
Speaker: The pleasure is all mine.
Speaker: So last time we were here, we talked about a very nerdy topic in terms of new vasopressors being launched in the arena for critical care illness.
Speaker: And today we're going to talk about something that's much more broad and encompassing, but really affects almost every interaction we have with patients in medicine.
Speaker: So I think that it would be a good start by making sure that we define some basic terms.
Speaker: And one of the things that I always struggle when I hear about this, Steve, is that I think a lot of people talk about empathy and compassion as almost being the same thing.
Speaker: Yet I understand that there might be some differences.
Speaker: Could you start by defining those terms for us?
Speaker: I'd be happy to.
Speaker: So this is actually a specific topic, meaning definitions, that is in some circles, in some scientific circles, and specifically in psychological science, hotly debated.
Speaker: Researchers will fiercely debate
Speaker: nuances of these definitions, but I can tell you that from going through the literature, there is some consensus, and I can define these terms for you as follows.
Speaker: Empathy has been defined as the mirroring or understanding of another's emotions, the emotional experience of another's feelings.
Speaker: Compassion, however, is a bit different.
Speaker: Compassion has been defined as the emotional response to another's pain or suffering involving an authentic desire to help.
Speaker: So as opposed to empathy, the feeling or understanding component, compassion is different in that it also involves taking action.
Speaker: And there are actually neuroscience underpinning the distinction in these definitions.
Speaker: What I mean by that is using functional MRI, neuroscience research has found that when you are experiencing another's pain, it will hit you in the part of the brain that is a pain sensor.
Speaker: But when you're focused on taking action to resolve someone's pain or suffering, that it activates in an area of positive emotion, affiliation, an entirely different neural structure
Speaker: And so compassion, taking action, and the feeling component actually are distinct, not only in these definitions that I provided you, but actually in different parts of the brain.
Speaker: So I think it would be fair to say that the biggest difference has to do with an action that we initiate to relieve that human being's pain.
Speaker: Now, I presume then you can have empathy for somebody without being compassionate in terms of your actions.
Speaker: But what about the reverse?
Speaker: Can you be truly compassionate without having empathy first?
Speaker: I think that some scientists would debate on this.
Speaker: My feeling is that empathy is almost a prerequisite for compassion, because if you're not feeling or understanding another person's pain or suffering, it's unlikely that you're actually going to be motivated to take action to try to relieve it.
Speaker: So I look at it as empathy as being a foundation, and then the compassion comes next.
Speaker: And the last question regarding this, I think this is a fascinating topic.
Speaker: And like you said, if we really got into the nitty gritty of the sociological, psychological science, we could be debating the terms for the whole podcast.
Speaker: But is there an element on the receiver end in terms of appreciating that compassion?
Speaker: Could I believe I'm being compassionate, activate the right sensory parts of my brain, but yet the person receiving that action does not see me as compassionate?
Speaker: Absolutely.
Speaker: In fact, there is quite a bit of data to suggest that physicians specifically, we could talk about healthcare providers broadly, but the data in this respect is mostly regarding physicians.
Speaker: Physicians don't often have a very good calibration for how compassionate they are or are not, meaning that the patients themselves
Speaker: can have a very different experience.
Speaker: In fact, there's some data that suggests that a third party, like nurses, more line up with the patient's assessment of a physician's compassion than a physician's own assessment.
Speaker: And so there can be some discordance there.
Speaker: And the available data that suggests that compassion is meaningful in healthcare is most closely linked with the patient's experience, so the patient's rating of the physician's compassion, not necessarily the physician's rating of the physician's compassion.
Speaker: Excellent.
Speaker: In a previous episode of Critical Matters, Steve, with Dr. Brown, we had discussed the concepts of dignity and respect in the ICU.
Speaker: And it seems to me that the first step is recognizing the dignity of every life, respecting that.
Speaker: The next building block seems to be having empathy for what is going on with their life and their position in life and what they're suffering.
Speaker: And it would seem that the fourth and last building block of this progression would be the ability to act with compassion, which is having deliberate actions to relieve or improve somebody else's life.
Speaker: Would you agree with that concept?
Speaker: I agree with it, and some of the literature on the topic of dignity and respect are what actually led me to an interest in compassion science in the first place.
Speaker: So, for example, I often say that we're experiencing a compassion crisis in healthcare, and we can talk about that if you'd like.
Speaker: But there are two specific ICU-based studies that really speak to this.
Speaker: So one is specifically regarding a study on dignity and respect in the ICU.
Speaker: It's a Johns Hopkins study published in Critical Care Medicine just a couple of years ago.
Speaker: And in this study, trained observers said about measuring healthcare providers' verbal and nonverbal communications related to maintaining patient dignity and respect in the intensive care unit.
Speaker: And what they found was that in 74% of the interactions in the ICU,
Speaker: they found that the healthcare providers showed no compassion for patients or families.
Speaker: And this is with a trained observer using a validated scale to code the different behaviors by the healthcare providers.
Speaker: And the healthcare providers didn't know what these third-party observers were actually measuring when they coded it.
Speaker: There was no compassion in three-quarters of the interactions.
Speaker: That's striking to me.
Speaker: Likewise, there was a study from the University of Washington a few years farther back.
Speaker: This is an NIH-funded study.
Speaker: Researchers found that fully one-third of end-of-life discussions with families in the ICU had zero statements of compassion by healthcare providers.
Speaker: And that, to me, is striking.
Speaker: I mean, if at any point in one's life,
Speaker: compassion is needed.
Speaker: It would be an end of life discussion.
Speaker: And in one third of those, there were zero statements of compassion with using validated scales to code the different behaviors.
Speaker: That, to me, speaks volumes.
Speaker: And so much of what's been done in the dignity and respect realm
Speaker: has led us to these data that show that compassion is lacking.
Speaker: And these are some of the data that I find compelling that got me interested in the topic in the first place.
Speaker: And I think that, as you mentioned in our offline conversations, and I've seen you talk about this before as well, the fact is that despite of what physicians believe, there is staggering evidence that from a patient's perspective and from an objective perspective, the lack of compassion is truly endemic and problematic at a very high level.
Speaker: Absolutely.
Speaker: Actually, one could argue that we just have a lack of compassion in society in general, but that's a totally different talk for a different day.
Speaker: It might be natural that by extension, it's bleeding over into healthcare as well.
Speaker: I don't know the cause of it or all the different causes of it, but what you just said is absolutely true.
Speaker: So, for example, a Harvard University study that was published in Health Affairs showed that nearly 50% of patients
Speaker: in the US believe our healthcare system and our providers are not compassionate.
Speaker: And other survey data showed that two-thirds of patients have had a meaningful lack of compassion, healthcare experience.
Speaker: And there are numerous studies that show that physicians miss the vast majority of opportunities to respond to patients with compassion
Speaker: and that only 1% of physicians' communications with patients are expressions of compassion.
Speaker: Now, these data are not just U.S. data.
Speaker: This isn't just a U.S. phenomenon.
Speaker: So there are data on this in the U.K.
Speaker: There are data in Ireland.
Speaker: There's global data on this, so this is not a U.S. thing.
Speaker: And importantly, it's probably being fueled to some extent by the epidemic of burnout that we're already well aware of.
Speaker: because burnout, one of the cornerstones of burnout, is depersonalization, which is an inability to make a personal connection.
Speaker: And this is just exacerbated by the era that we're in right now with electronic medical records, where there is robust data to show that healthcare providers in all different practice domains, whether it's office practice or in the hospital,
Speaker: we spend more time looking at our computer screens and looking our patients in the eyes.
Speaker: And that's, I think there's plenty of data across all these different areas to show that we really do have a capacity crisis.
Speaker: And that's what I think is the biggest problem we have today.
Speaker: And I think that you mentioned a lot of these factors that we'll touch back on, but I think that just as a comment, it's interesting that I recently saw a study that had been replicated after several decades regarding how long does it take on average for a physician to interrupt a patient who's giving them a history.
Speaker: And several decades ago, it used to be 22 seconds.
Speaker: And now with all the electronic medical record and the computers that we seem to be obsessed with, it's at 11 seconds.
Speaker: So we have become much more efficient and an interrupting patient.
Speaker: But the question is, have you become more effective in making them feel compassion and understanding what's going on with them?
Speaker: I'm aware of that data and I agree totally.
Speaker: So you talked about society.
Speaker: We talked about how you got interested into this topic a little bit.
Speaker: But what about the term compassionomics?
Speaker: That's a term that you have shared with me on previous conversations, and it's a term that I had not heard before.
Speaker: Could you tell us what compassionomics really is?
Speaker: Well, you didn't hear it before because I made it up.
Speaker: But the idea here is that we want to be rigorous in the approach of
Speaker: and we don't want to just try to convince people of the importance of compassion via emotional type of appeals.
Speaker: There is a huge amount of data on the fact that caring makes a difference.
Speaker: And in using the term compassionomics, I'm just trying to draw attention to the fact that we ought to take a rigorous
Speaker: approach, quantitative when possible.
Speaker: And I define compassionomics as an emerging field of compassion science.
Speaker: It's essentially the convergence between the science and the art of medicine.
Speaker: More specifically, I look at compassionomics as the study of the effects of compassionate care on health.
Speaker: health care and health care providers.
Speaker: So my thinking in developing Compassionomics is that we need to dispel the myth that compassion science is just something soft that is the basis for emotional appeals.
Speaker: And first of all, make ourselves aware of all the data that's actually available.
Speaker: and then going forward have a very rigorous research agenda because there are very testable hypotheses in compassion science and it's just now on us to be rigorous in the approach to test these hypotheses in rigorous ways to add to the body of evidence.
Speaker: And I understand that there are many questions or hypotheses that need to be tested.
Speaker: There also seems to be a vast amount of already published literature that I know that you have spent some time evaluating in a very rigorous way.
Speaker: And I would like to talk a little bit about that, Steve, the science behind compassion.
Speaker: And at Sound Critical Care, obviously, we strive to provide value, which we define as better patient outcomes,
Speaker: over lower cost.
Speaker: And I think that we would like to start by maybe asking you to talk a little bit about the science or the data behind the impact of compassion on patient outcomes first.
Speaker: Sure.
Speaker: Let me just back up just a little bit before we get into that.
Speaker: And we talked a little bit about what we call the compassion crisis.
Speaker: Well, there's two possibilities, right?
Speaker: Possibility number one, it doesn't matter.
Speaker: Possibility number two, it does matter.
Speaker: And if it does matter, how does it matter, when does it matter, how much does it matter?
Speaker: Stated another way, knowing with all the data that we reviewed that compassion is lacking in healthcare and it seems to be striking, a follow-on question to that could be, well, who cares?
Speaker: Does compassion really matter?
Speaker: Obviously, it has always been a fundamental component of the art of medicine.
Speaker: There's an ought there.
Speaker: We ought to treat patients with compassion.
Speaker: There isn't anybody, I don't know anybody, that would argue with that.
Speaker: The question is, does it matter in a scientific way, and are there measurable effects that actually belong in the domain of science, in the evidence-based medicine domain,
Speaker: and not just a nice-to-have that belongs in the art of medicine.
Speaker: And so I, over about two years, went through the scientific literature using National Library of Medicine, PubMed, and conventional systematic review methodologies to test the hypothesis that compassion matters.
Speaker: And so my hypotheses were that compassion matters for patients, for patient care,
Speaker: and for those who care for patients.
Speaker: And so I went through about 1,000 or more scientific abstracts, more than 200 research papers, and I found an unbelievable amount of data, even going back decades, studies that were perhaps had gone missing, so to speak,
Speaker: even those that are published in the New England Journal of Medicine and came from some of the most influential ivory towers in academia, the question is how do these studies go missing?
Speaker: And I think it's because in contrast to more conventional medical science research where studies connect to each other and then they
Speaker: they build up and they build up to this body of evidence.
Speaker: I think that these studies have made little ripples and splashes, but they never really connected to each other to form a wave of, and when I go back and look at all these data now, and I see it now in its totality, it's just obvious to me that compassion matters not only in meaningful ways, but in measurable ways also.
Speaker: So, in talking about, you asked me about patient outcomes, and I can tell you that in my systematic review and research related to that, there are more than 20 distinct mechanisms of action by which compassion can have beneficial effects on patients.
Speaker: And, you know, I know we don't have time to get into all the data today in the short amount of time on this podcast,
Speaker: I can just broadly group them into just general categories.
Speaker: One is quality.
Speaker: If you care deeply about patients, you're more likely to be meticulous about their care and have higher quality standards.
Speaker: You might be at lower risk of making a major medical error.
Speaker: And there's lots of data on that.
Speaker: There are also, though, physiological effects.
Speaker: So by harnessing the parasympathetic nervous system, compassion for others can buffer stress-mediated disease.
Speaker: It can also modulate a patient's perception of pain.
Speaker: There are immune system effects, there are endocrine system effects.
Speaker: There are some really interesting studies showing that compassion for patients is associated with better glycemic control in diabetic patients and lower odds in metabolic complications.
Speaker: There's even research from the University of Wisconsin that shows that compassion for patients is associated
Speaker: with lower duration and severity of symptoms for patients with a common cold.
Speaker: One study I'll just finish with that I really think is compelling is a Johns Hopkins study from about 10 years back which asked 1700 patients with HIV if their doctor knows them as a person.
Speaker: And knowing the patient as a person
Speaker: was associated with 33% higher odds of adherence to therapy, but also at 20% higher odds of having no detectable virus in the blood.
Speaker: So knowing the patient as a person translated the better belief in therapy, actually taking your therapy, and then the physiological effects of clearing the virus.
Speaker: So this is just a broad overview.
Speaker: There are also many psychological health benefits to compassion in modulating anxiety and depression and even PTSD.
Speaker: But I'll just stop there and we can...
Speaker: We can talk about cost if you want to.
Speaker: Sure.
Speaker: So I think just to make sure, I mean, to summarize, it really seems that from your systematic review of the literature, you feel that the answer to does compassion help patient outcomes is yes.
Speaker: And perhaps future questions are how we can modulate that or how we can leverage that specifically in the ICU and in other fields.
Speaker: Absolutely.
Speaker: Absolutely.
Speaker: So, yeah, I think the second part of this equation, maybe you can think about the patients.
Speaker: The cost equation, I think, really applies to the healthcare environment or the healthcare system.
Speaker: And how does compassion impact cost or the healthcare system itself?
Speaker: Sure.
Speaker: The most compelling data, in my opinion, well, first of all, if compassion impacts
Speaker: promotes or supports financial sustainability at healthcare organizations, it could be in a couple of different ways.
Speaker: One is to augment revenues.
Speaker: The other is to decrease costs.
Speaker: So in terms of revenues, there is, in my opinion, an overwhelming amount of data that shows that
Speaker: patient experience and the human connection that drives patient experience is what drives business in healthcare.
Speaker: So for example, there was a Wall Street Journal study from several years back which asked about 2,000 people, what are the most important qualities in a physician?
Speaker: Now, here to ask physicians, they might say,
Speaker: training in the best programs, having a lot of experience.
Speaker: And those things were somewhat important, but even less than 50% of respondents thought that those things were actually important.
Speaker: All the things that regular people thought were important in their health care were all the human connection factors.
Speaker: Not just dignity and respect and listening, but just truly cares about me was one of the most often
Speaker: most often cited factors by readers.
Speaker: And so that's what people are actually looking for in healthcare.
Speaker: And for healthcare providers, that might be surprising because we think, well, actually they want technical expertise, so why is it that the survey data indicates that they actually want human connection or value that over all these other things?
Speaker: And I think it's that regular people
Speaker: want to believe or do believe that all physicians know what they're doing.
Speaker: Now, within healthcare, we might have a different eye to that and think that there are important differences in technical abilities between physicians, but they don't necessarily see that, and the human connection part is what they really value, and there's just a ton of data on that.
Speaker: In terms of cost, there's a lot of data in primary care that shows that compassion for patients is associated with lower discretionary resource use.
Speaker: Lower diagnostic testing, lower referrals to specialists, and also lower total healthcare charges.
Speaker: from the primary care viewpoint, perhaps if we actually spend more time talking to patients, we don't need all these tests and referrals.
Speaker: The most important factor regarding cost, though, is actually in you and me, in healthcare providers, because turnover of physicians, there's an AMLs of Internal Medicine, sorry, JAMA Internal Medicine paper,
Speaker: earlier this year, which showed that every time you have turnover of a healthcare provider, specifically a physician, it costs a health system between $500,000 and a million dollars.
Speaker: And obviously burnout is one of the most important drivers of not only physician turnover, meaning leaving for another organization,
Speaker: but also just lower career longevity and just leaving health care in general.
Speaker: And there's a lot of interplay between compassion and burnout.
Speaker: So I think that that's a great lead into the following aspect that I wanted to ask you about, Steve, which relates to we talked about how compassion can have favorable impacts on patient outcomes, on the health care system itself in terms of containing cost, improving care.
Speaker: And finally, the other side of that equation are the providers.
Speaker: And we talked about a little bit at the beginning, you alluded to
Speaker: to the epidemic we have with physician burnout, something that's very talked about at multiple circles, but clearly something that affects critical care in a very special way, both at the critical care physician level and the critical care nursing level.
Speaker: What are the impacts of being compassionate on our day-to-day in terms of how we feel?
Speaker: Could you talk about that?
Speaker: Yeah, sure.
Speaker: I'd love to.
Speaker: So that's complex, but I think it's vital that we talk about it, especially
Speaker: in this podcast because intensivists, as you mentioned, are at the top of the list for burnout.
Speaker: So when I was going through medical school, I remember the conventional teaching was don't get too close to patients.
Speaker: So don't get too close to patients because then you're putting yourself at risk for burnout.
Speaker: I get that to some extent, but what happens when you go to the data, right?
Speaker: So I, as I mentioned, I went to the data, and if that were true, if that were true, then we would see high association between compassion and burnout.
Speaker: And when you look at the data, that's actually not what you find.
Speaker: In fact, there was a really well-done
Speaker: systematic review of in the burnout research literature published in 2017 which found that 90% of studies that involve healthcare providers actually found evidence of an inverse association between compassion and burnout so if you have an inverse association that's that's either high compassion and low burnout or low compassion and high burnout and
Speaker: we have to keep in mind that these are all cross-sectional studies.
Speaker: They're not longitudinal, so they're definitely not experimental.
Speaker: And so you can only conclude association rather than causation.
Speaker: And so sometimes we make the mistake of jumping to the assumption that when we see high burnout, low compassion, that burnout crushes compassion, when actually
Speaker: it is equally as likely that it's low compassion providers that are the ones that are predisposed to getting burned out.
Speaker: So the data shows an inverse relationship.
Speaker: The preponderance of evidence in the biomedical literature supports that.
Speaker: And I've actually had it in my own experience.
Speaker: I can tell you that
Speaker: a couple of years back, I had every symptom of burnout, like every single one.
Speaker: You know, my wife made the diagnosis, right?
Speaker: And she's not in healthcare, okay?
Speaker: It was pretty obvious.
Speaker: And, you know, I think these things have been troubling physicians for decades now.
Speaker: It's just that now we're,
Speaker: we talk about it more, we're more willing to open up and talk about it.
Speaker: Well, I definitely found myself there.
Speaker: Let me tell you, it's not a good place to be.
Speaker: And the question is, well, what are you gonna do about it, right?
Speaker: So since I'm a research nerd, like that's my thing, right?
Speaker: I'm a research nerd, I decided to take the research nerd approach and test the hypothesis that compassion
Speaker: can actually transform my own experience.
Speaker: So, supported with this data that I told you about, that 90% of the studies in healthcare providers find an inverse association between compassion and burnout, I went the other direction rather than escaping, because that's what all the
Speaker: advice had been historically.
Speaker: That's what most of the studies are like, you know, go on a nature hike or go do yoga or do whatever.
Speaker: And all those things are important.
Speaker: I'm not discounting the value of those things.
Speaker: I think those things are really important for well-being.
Speaker: But I thought that my thinking was that the antidote to burnout had to be at the point of care.
Speaker: And so I just did an experiment where I was, I was the end of losing end of one experiment experiment.
Speaker: And I was the one.
Speaker: So I leaned in, I gave more compassion, I tried to care more.
Speaker: And that was transformative for me.
Speaker: It transformed my experience.
Speaker: uh i uh and all i can advise is if if anybody on the podcast and i know uh sergio now you've got like 30 000 listeners or something like that if there's anybody out there and playing the odds it's like 50 so there's probably a whole lot of people um i can't guarantee you that it's going to transform your experience but if you lean in and you treat patients with more compassion
Speaker: Just see what happens, because it changed everything for me.
Speaker: And obviously, that's anecdotal evidence, for sure, in your N of 1, but it was the most meaningful experiment that I know about for me.
Speaker: And I think, Steve, we'll touch on two very important points in this, but I would agree from personal experience, not only being compassionate with our patients, but being compassionate with ourself and with our coworkers makes a big difference.
Speaker: And I have found, for example, that a simple practice that has transformed the way I look at doing night shifts, which I don't enjoy as much as I presume a lot of our intensivists would feel the same way, is to every night shift, find a coworker.
Speaker: whether it be the radiology tech, the person who cleans up the ICU room, one of the nurses, and heartfully thank them for their contributions to caring for our patients.
Speaker: And as you do those things, I think you start transforming the way you feel and the way you think about the people who work with you.
Speaker: And I'm sure it's the same with patients.
Speaker: And the question I have for you to follow up, Steve, is,
Speaker: A lot of people believe, and I think it's rooted in the advice we heard at med school, don't get too personally involved because too much of that caring, too much of being involved at an emotional level could be very hurtful and could actually lead to burnout.
Speaker: But do you think that there's a sweet spot?
Speaker: Do you think that too much compassion could be bad?
Speaker: Or do you think that we're looking at the wrong way?
Speaker: Well, listen, um,
Speaker: Osler referred to a detached concern and certainly there's got to be great wisdom in that.
Speaker: So I definitely get it and that there has to be some sort of psychological or emotional protection for the caregiver to some extent, but
Speaker: At the same time, let's keep in mind how we made our definitions at the beginning of the podcast, right?
Speaker: So there's, and I don't want to get too nerdy about this, right?
Speaker: But there's empathy and then there's compassion.
Speaker: And empathy is the feeling or understanding component.
Speaker: And I told you that there's neuroscience data, functional MRI, that shows that that hits you in the pain center, right?
Speaker: So when you can literally, we figuratively say,
Speaker: all the time, oh, I feel your pain, right?
Speaker: Well, you can literally feel somebody's pain and it's shown on your functional MRI.
Speaker: That is not a figure.
Speaker: It's actually happening to you.
Speaker: And that's why it hurts when you see somebody suffering.
Speaker: What I would tell you is that if we are constantly in a state of being affected by everything around us, it is no doubt going to take a psychological and emotional toll on us.
Speaker: That is obvious.
Speaker: I think that's just sort of intuitive.
Speaker: Compassion is different, and we said compassion involves taking action, and we also mentioned that compassion involves taking action that actually activates different brain pathways.
Speaker: It's a different experience.
Speaker: It triggers positive affect.
Speaker: It triggers positive emotions.
Speaker: So I guess I'm agreeing with you that to some extent you have to be worried about protecting yourself.
Speaker: I get that, but at the same time, taking action really can transform the experience
Speaker: And I believe that that's actually data-driven.
Speaker: And I think that also what I feel from my own personal journey and talking with you and thinking about this as a practitioner, but also as somebody who has a lot of colleagues that work in clinical care has been that really it's not certainly the utmost suffering with every case and getting down to that personal level where we feel affected, everything that's going to the patient.
Speaker: But I think it's maybe taking a step back and realizing that
Speaker: we can do things or what are the things in our control to make that suffering better?
Speaker: What are the things in our control to make that patient feel or that family feel that they matter?
Speaker: And I think that if you do that on a regular basis, you start getting better at it.
Speaker: But I do think that, like you said earlier, it not only has probably tremendous impact on the patients we care for,
Speaker: but also on ourselves.
Speaker: Which leads me, Steve, to my second important question on the topic of compassion related to the providers.
Speaker: I think that like many other traits in life, the common wisdom has been that Dr. X is compassionate, Dr. X or Dr. Z was not born compassionate, and that these are innate abilities that people have.
Speaker: Yet over and over again, what we're learning is that anything can be learned and that ultimately these qualities are much more of being made than people being born with them.
Speaker: Could you comment on that?
Speaker: Yeah, absolutely.
Speaker: That's what I used to think.
Speaker: I used to think that people were either wired for compassion or they weren't.
Speaker: You know, like it's in their DNA.
Speaker: Yeah.
Speaker: And there actually is some data that shows the DNA polymorphisms, there may be some genetic basis to human connection as well.
Speaker: But that notwithstanding, there is an overwhelming amount of evidence.
Speaker: In fact, in a recent systematic review, the investigators found
Speaker: that in the most methodologically rigorous studies of interventions to raise physician compassion, 80% of studies found the intervention to be effective.
Speaker: So it resulted in more compassionate behaviors.
Speaker: So the preponderance of evidence in the biomedical literature shows quite clearly that compassionate behaviors can, in fact, be learned.
Speaker: So even if someone believes, well, you can't teach, train somebody to care, well, you can train somebody to communicate their caring.
Speaker: And that is shown quite clearly in the data.
Speaker: So I used to believe that we're either wired for it or not, but actually, if you look at the data, the data says that change is possible.
Speaker: And that's good news for somebody like me.
Speaker: I'm trying to get better every day.
Speaker: And I think it should be good news for everybody.
Speaker: But before we go down that rabbit hole, Steve, let me ask you, or let me pose the devil's advocate and say, well, Dr. Treziak, I hear what you're saying.
Speaker: This is all fantastic.
Speaker: It would be wonderful.
Speaker: Like it'd be wonderful to have a lot, to have a perfect medical record system, which doesn't take my time.
Speaker: But the reality is on a daily basis, shift in and shift out.
Speaker: There's so much stuff I have to do as a provider.
Speaker: There's so much crap I have to deal with that I just don't have time to be compassionate.
Speaker: How would you respond to that?
Speaker: Yeah, I think that that is super important.
Speaker: There was a study from Helen Reese's laboratory published in a few years back that found she's a at Mass General and one of the thought leaders in compassion science and
Speaker: And what her research found was that when physicians were asked a question, do you have enough time to be compassionate, 56% said no.
Speaker: And that's pretty striking, right?
Speaker: I totally understand that as an intensivist myself.
Speaker: You're constantly feeling like you're behind in getting all your patient care activities done for the day.
Speaker: This is certainly a clear and present challenge to human connection and compassion.
Speaker: So the next really important question is, how long does it take?
Speaker: Because I think a lot of people think, well, it takes a long time.
Speaker: Is that true?
Speaker: So I'll be brief in the interest of time, but there's a study from Johns Hopkins
Speaker: in cancer patients.
Speaker: It was a randomized trial in cancer patients.
Speaker: And the randomized trial was testing a compassion intervention versus standard consultation.
Speaker: And in the compassion intervention, there were standardized behaviors to communicate compassion for patients.
Speaker: And primary outcome measure was anxiety.
Speaker: And now some people might think, well, that's not a hard outcome measure like a physiological one.
Speaker: Well, let me tell you, if you have cancer, it's a pretty important outcome measure.
Speaker: So what they tested was this intervention and it reduced patient's anxiety.
Speaker: So how long did it take?
Speaker: What they found is that the intervention took 40 seconds.
Speaker: Another study from Memorial Sloan Kettering found that in a real-world situation, not in the confines of randomized control trial, found that it takes 31.5 seconds.
Speaker: And another recent study, they found that it takes 38 seconds.
Speaker: So that's three studies right there, all with very rigorous methodology, in my opinion, and from reputable investigators, that show somewhere between 31 and 40 seconds is what it takes to communicate
Speaker: compassion to a patient in a meaningful way.
Speaker: So now 56% of people say, well, I don't have time to treat patients with compassion.
Speaker: Do you really?
Speaker: I mean, it's 30 seconds.
Speaker: I mean, you know, I, there are 40 seconds in the Johns Hopkins study that I described here.
Speaker: So that doesn't totally hold up in my opinion.
Speaker: And from the psychological science data,
Speaker: there's this concept of time affluency, meaning the feeling of having enough time, having a wealth of time versus feeling like you're always behind and you're always in a rush.
Speaker: And what those studies have found is that your other focused time, focusing your time on other people make you feel like you have more time.
Speaker: So giving time might feel that you actually have more time.
Speaker: And it might change how you feel about whether or not you have enough time to show compassion for patients.
Speaker: And I think it speaks also in general what you're mentioning, Steve, of how we can learn these behaviors to the whole paradigm that I think has changed over time of leadership.
Speaker: People believe that leaders are born.
Speaker: I think more and more we realize that leaders are made actually.
Speaker: And also how that transition happens in multiple areas of life in terms that people think that if I'm wired for something, I will do it well.
Speaker: as opposed to if I start behaving in a certain way, I will rewire myself and I become better and better at this particular action, which in this case could be compassion.
Speaker: So if you had to give us three to five top Tresiac tips of how we could today become more compassionate with our patients, what would you tell us, Steve?
Speaker: Sure, I just would first like to comment.
Speaker: I totally agree on what you just said.
Speaker: There's overwhelming data on neuroplasticity and the fact that you can actually change your brain.
Speaker: The other thing is that if you can't change your brain in that sense, you can certainly shift your mindset.
Speaker: And there's been, obviously, a ton of work on mindset, not only in healthcare, but in education and a lot of different areas.
Speaker: So changing your mindset is actually something that can be done.
Speaker: Your question was, what are my three to five tips to become more compassionate?
Speaker: Is that right?
Speaker: Yep.
Speaker: So number one, I would say don't don't be afraid to cross the professional Rubicon, quote unquote.
Speaker: What I mean by that is goes back to a study or sorry, an article that was in the Boston Globe magazine.
Speaker: more than two decades back.
Speaker: It was written by Kenneth B. Schwartz.
Speaker: And if you've ever heard of the Schwartz Center for Compassionate Healthcare, that's Kenneth Schwartz.
Speaker: And obviously that organization has touched the lives of countless people across the US and internationally over the last 20 plus years.
Speaker: Well, he wrote an article in the Boston Globe
Speaker: called A Patient's Story.
Speaker: And in that, his advice to his patients, and he was dying of cancer, and what was striking to him was the fact that these small acts of compassion from people truly transformed what he went through at the end of his life in a really meaningful way.
Speaker: And obviously he never,
Speaker: had the opportunity to know the impact that he would have, but the ripples from that now are just really tremendous in what the Schwartz Center's been able to do over the last 20 plus years.
Speaker: But what he said repeatedly in that article, he talked about crossing the professional Rubicon and not being afraid to do it.
Speaker: So just yesterday, a colleague came in to my office, another intensivist,
Speaker: who is highly experienced, been here for a number of years, and we talk about compassionomics not infrequently, the two of us.
Speaker: And he said that for the first time he tried to do something, or he started to do something that he had never done before.
Speaker: He wrote a card to patients and families after they were discharged from the ICU
Speaker: and he took it to their bedside up on the medical floor a couple days after they were transferred out of the icu and um it was just a card that expressed gratitude for having the the privilege of taking care of them and that connecting with them
Speaker: was meaningful and just giving them a heartfelt, just communicating that he cared a lot.
Speaker: And what he told me now is that it transformed his entire week, right?
Speaker: So that was something that was a Rubicon, so to speak, for him.
Speaker: He had never done that before.
Speaker: And now he's having a totally different experience.
Speaker: I think that that's powerful.
Speaker: So that's number one.
Speaker: The next things I would go is a short list
Speaker: And it's just overcoming the barriers to compassion or recognizing what they are and then addressing them.
Speaker: So here's what I mean by that.
Speaker: I think there, in my opinion now, this is just my opinion, there are four main barriers
Speaker: or reasons why providers, whether the physicians or nurses, any kind of healthcare provider might not treat people with compassion.
Speaker: So number one is, I don't think it really matters.
Speaker: Well, we talked about a lot of data that compassion impacts patients and outcomes in meaningful ways.
Speaker: I will give you the caveat, and I need to say this loud and clear, and I meant to say it earlier,
Speaker: Compassion is not a panacea, right?
Speaker: It's not a substitute for quality technical care.
Speaker: So if you miss a diagnosis or you prescribe the wrong drug or you botch a surgery on somebody, there's no amount of compassion in the world that's going to make up for that, right?
Speaker: But recognize it's not an either or, right?
Speaker: It's an and.
Speaker: Compassion and technical care are not mutually exclusive, right?
Speaker: They're supposed to be an and, not an either or.
Speaker: So compassion on top of quality technical care can make a meaningful difference.
Speaker: And so this notion that I don't think it really matters, I personally, after my 1,000 scientific abstracts, 200 research papers, I don't believe that anymore.
Speaker: I don't think it holds up.
Speaker: I think that
Speaker: compassion matters and it matters not only in meaningful but measurable ways for patients.
Speaker: So that's number one.
Speaker: Number two is the I don't have time.
Speaker: And we just talked about that.
Speaker: You probably do have 40 seconds, right?
Speaker: So that's probably not a good reason to not treat patients with compassion either.
Speaker: Number three would be I don't care.
Speaker: Well, that's probably
Speaker: a statement that's reflecting burnout, right?
Speaker: And we talked about that earlier too.
Speaker: So in my own experience, when I was experiencing that, I found that working harder in compassion transformed that experience.
Speaker: So that's probably not the best reason not to provide compassion either.
Speaker: And the last one then is just, I don't know how.
Speaker: And that's a totally valid, that's a totally valid,
Speaker: position to take because it just comes naturally to some people and it comes and it doesn't to others.
Speaker: But the preponderance of evidence in the biomedical literature shows quite clearly that change can happen, that compassionate behaviors can in fact be learned.
Speaker: And so really my tips, I think, as you framed it, was number one, don't be afraid to cross the Rubicon.
Speaker: because it can transform your experience.
Speaker: And then these things like, I don't think it really matters, I don't have time, I don't care, and I don't know how, when you really look at the data, those things probably don't hold up.
Speaker: And if you realize that, and you recognize that, and you're honest with yourself, then you realize that there's really no reason not to treat people with compassion.
Speaker: And oh, by the way, right, we ought to treat patients with compassion.
Speaker: It's not really that compassion needs a justification, right, because we ought to be doing these things anyway.
Speaker: Because even if there weren't any data, I think the vast majority or hopefully everybody on the podcast would agree it's something that we ought to do.
Speaker: Yeah, and I think that we've found in medicine over and over again, as in life, that things that we ought to do because of human nature don't necessarily happen on a regular basis in real life.
Speaker: But I think that those are very powerful.
Speaker: And I will try to put the article by Dr. Schwartz in the show notes as something probably worthy of exploring.
Speaker: Like you said, I think that I really like that concept of crossing the profession of Rubicon,
Speaker: And really, I mean, trying to connect with people at a personal level.
Speaker: So I think that this has been a phenomenal conversation, Steve.
Speaker: I know that you're working on a lot of interesting projects in the field of compassionomics.
Speaker: So I'm sure that we will have you back on the podcast again.
Speaker: You're also the first guest to come back for a second topic and quite a different topic.
Speaker: I think we've pivoted.
Speaker: 180 degrees in a different direction, but I think that a direction that obviously is extremely, extremely important.
Speaker: So as a seasoned Critical Matters guest, you know that at the end we usually ask some questions not related specifically to the topic.
Speaker: Since you have already answered those questions, I thought that I would ask a couple of those questions within the context of Compassionomics, which I think would be a nice way to close.
Speaker: Would that be okay?
Speaker: Sure.
Speaker: So I think that the two questions I have for you, the first one is, what do you believe to be true about compassion in medicine that most other people don't believe right now?
Speaker: Oh, wow.
Speaker: So I'll answer the question.
Speaker: I don't know.
Speaker: It's not most, though.
Speaker: I would say some can answer it that way, right?
Speaker: Fair.
Speaker: Right?
Speaker: Okay.
Speaker: So what do I believe about compassion that some people don't believe?
Speaker: Well, in healthcare, and so this is just in the domain of my opinion, right?
Speaker: So in healthcare, we often encounter people who have serious health conditions that could be framed at least to some extent as being self-inflicted, right?
Speaker: There's a lot of evidence in psychological science to show that oftentimes people have lower compassion for people in that kind of a situation.
Speaker: You might have seen it in where you practice.
Speaker: I sometimes see it where I practice.
Speaker: Typically, it involves people that have some sort of addiction.
Speaker: So I'll tell you just what I think.
Speaker: This is my personal belief.
Speaker: No one ever deserves it, right?
Speaker: So there's no such thing because, and this is what I believe, right?
Speaker: No one in the history of the world, no one ever wakes up in the morning and says,
Speaker: hey, you know what's a great idea?
Speaker: I think I'm gonna start, I wanna get addicted to heroin today, right?
Speaker: Or no one wakes up in the morning and says, hey, I think it's a great idea, I think I'm gonna try to go get hooked on smoking or alcohol, right?
Speaker: And so certainly there are elements in all of these things that reflect poor personal decision making.
Speaker: There's no doubt about it, right?
Speaker: But no one deserves it, and they all deserve our compassion, and I think we should just treat them accordingly.
Speaker: And sometimes those are the most challenging patients, but I think if you look back at the oaths that we all took when we started our journey in being physicians or other healthcare providers, no one ever deserves it, and those people actually
Speaker: can respond to our compassion in some of the most powerful ways.
Speaker: And I would actually interject and say that this is something I think most people
Speaker: disagree with you in terms of not whether they believe it or not in a conversation, but in terms of how we act.
Speaker: And I think that every ICU will see frequent flyers, will see people who come over and over again, will see patients with all sorts of, like you said, addictions and consequences of that.
Speaker: And I think that over and over again, there is a lack of compassion with these patients.
Speaker: So I think it's something to point out to the universal
Speaker: dignity of a human life and the universal, I think, requirement that we treat everybody with compassion.
Speaker: I think that's very powerful, Steve.
Speaker: So the last and final question would be for all our listeners, for all our providers in critical care who are listening to our podcast today, what would you want them to know about Compassionomics?
Speaker: So,
Speaker: Compassion science is not soft.
Speaker: It's not mushy.
Speaker: It's only soft and mushy if you approach it that way in your brain, right?
Speaker: So I would just say be open.
Speaker: Be open to the available data.
Speaker: I'm in the process of trying to be the curator now and try to put all this together in a way
Speaker: that it can be synthesized and easily digested.
Speaker: But be open to the idea that it's not just an emotional appeal, but actually a scientific and an appeal, a scientific case and one that is based on reason.
Speaker: So for example, like Darwin, right?
Speaker: So everybody thinks, well, Darwin was survival of the fittest.
Speaker: So that's like anti-compassion.
Speaker: But did you know that Darwin never coined the phrase survival of the fittest?
Speaker: He was a different guy named Herbert Spencer, who was a British guy, biologist, anthropologist.
Speaker: And so he read Darwin's stuff and coined the phrase survival of the fittest.
Speaker: And then over time, this framing sort of just morphed.
Speaker: and got misconstrued.
Speaker: And so the widely held belief that Darwin's views were justification for like aggressive gladiator type behavior.
Speaker: And that's not at all what Darwin said.
Speaker: Actually, if you look into descent of man, what he concluded was that having greatest compassion, having the greatest compassion for others would yield a community that would flourish the best,
Speaker: and reared the greatest number of offspring.
Speaker: So I think there's no doubt that Darwin was one of the most important scientists in history.
Speaker: And the body of scientific evidence, including what Darwin himself said, suggests that compassion actually protects the species.
Speaker: So I just don't think of it as soft and mushy, at least
Speaker: Historically, maybe, we haven't put the rigor to it that we have with other elements of medical science, but I think we can do it to compassion as long as we take a similarly rigorous approach, and that's what I want you to know.
Speaker: And I think that's a great place to close.
Speaker: And what I would say is evidence-based compassion, something you can apply to every patient you meet today.
Speaker: Steve, such a pleasure to talk with you about this fascinating topic.
Speaker: I think that we look forward to having you again on Critical Matters.
Speaker: And I just want to thank you in the name of our audience for your generosity with your time and your passion for this topic.
Speaker: Thank you very much.
Speaker: Oh, it's my pleasure.
Speaker: Thank you so much, Sergio.
Speaker: Thanks again for listening to Critical Matters.
Speaker: Make sure to subscribe to this podcast on iTunes or Google Play.
