15 Nov A Small Dose of Compassion Does Wonder
We, as a society, think quite often that our behavior follows the Darwin view on natural selection of the fittess. It is not a justification for aggressive or ruthless behavior, which in many ways, leads to discrimination, abuse, bullying, war and worst, cleansing of ethnic groups of people. A compilation of systematic review is considered one of the most important tools for establishing and examining health care issues , such as compassion.(1) The Oxford Handbook of Compassion Science (2017) , (2) includes a collection of academic research publications and work on compassion. There is a paradox about politicians giving lip service to compassion while health and wealth inequality is growing exponentially. When wealth and health inequality grows so far apart, people may feel they have nothing to lose and unrest may appear. In reality, everyone deserves the right to dignity, to food, to shelter, to security, to health care.
American physicians Stephen Trzeciak and Anthony Mazzarelli sounded the alarm about systemic inhumanity within patient-based medicine. In their book, Compassionomics, 2018 (3) , they showed that there is knowledge and scientific studies with revolutionary evidence that caring makes a difference. There is a compassion crisis in the health care system of US and Canada, perhaps the world. Evidence shows that treating patients more kindly improves health outcomes, reduces doctors burnout and lower costs of providing care.
Science of medicine is how to treat a patient, while the art of medicine is how to care for them, building rapport, connection and trust.
Compassion is an integral part to that belief system and is defined as the emotional response to another’s pain or suffering, involving an authentic desire to help. Empathy, on the other hand, is the feeling and understanding component of pain and suffering. Feeling empathy is a necessary precursor to motivate acts of compassion. Empathy hurst but compassion heals. Empathy is feeling, compassion is action.
The compassion crisis could turn the profession of healthcare providers from a calling into a job. Health care needs to be a calling. Walking with people through the worst, most intimate moment of their lives is sacred, that requires a level of personal interest. When patient’s health is at stake, time, emotion, empathy and compassion should be non-negociable.
Physicians work in emotionally-charged situations associated with suffering, fear, failures and death, culminating in difficult interactions with patients, families and staff. Health professionals are held by society and also hold themselves to high standards of skills, knowledge and performance. It is believed they should always be at the peak of their ability to do whatever is needed and be emotionally available and compassionate. The rewards for this level of commitment are status, admiration, respect, proper equipment, space to do our jobs and financial compensation. All of these expectations are changing, as there has been a dramatic decrease of control and autonomy in patient-physician relationship, conflicts with peers, over controlled by staff and administration, and yet we continue to fulfill our side of the contract with a sense of confusion, disbelief and wondering where it will lead us. All of these factors contribute to increasing levels of anger, frustration, stress and yes, burnout.
Burnout is a syndrome and can be a combination of exhaustion, emotional and physical. Burnout has many characteristics including: fatigue, exhaustion, inability to concentrate, depression, anxiety, insomnia, irritability and increased addictions. The most distinct characteristic is a loss of interest in work which can lead to a low sense of accomplishment, decreased job performance, reduced job commitment and low career satisfaction.
Factors independently associated with burnout include younger age, having children, area of specialization, numbers of night on-call per week, numbers of work hours per week, and having compensation entirely based on billing.
- A nationwide, multispecialty survey of more than 2000 physicians in 2011 (4) found that almost 87% of respondents felt moderately to severely stressed and almost 63% admitted feeling more stressed and burnout now than they had felt 3 years ago. (“Mid-career burnout in generalist and specialist physicians”, “Burnout and career satisfaction among American surgeons”, “Results from CMA’s 1998 physicians survey point to a dispirited profession”, “Physicians Burnout”)
- A new survey by the Canadian Medical Association published in 2018, (5) completed by 2,547 physicians and 400 medical students reported elevated burnout in more than one in four physicians and in 48% of medical students. Interestingly, physicians in practice for more than 30 years had the higher sense of well-being.
The trend from current studies (6,7,8) still suggests the rate of emotional exhaustion, fatigue, tiredness, excessive amounts of work, lack of personal and family life balance is around 30-38%. It is supported by national samples of members of subspecialty societies. Almost 2/3 of Canadian physicians (62%) have a workload they consider too heavy and more than half (50%) felt their family and personnel life has suffered; 27% said they were on-call too often. Studies suggest that difficulty balancing personnel and professional life, administrative tasks, lack of autonomy and patient volume are the greatest sources of stress.
A study from the Annals of Internal Medicine (9), showed that 75% of physicians interrupted patients before their completed giving their information. Many studies found that 56% of physicians do not have time to treat patient with compassion. There is a continuous push to see more patient, financial pressure, cost of running office, increase EMR, documentation, administrative burden and more.
If mentors role model a lack of compassion in the day to day work with patients, new physicians in training will learn to do the same. Another study from John Hopkins, showed that residents spent 12% of their time seeing their patients while 40% doing computer work. (10,11)
Benefits of compassion:
The question is: how do we foster compassion within systems designed to reward those who aren’t compassionate? How do we change the mentality that the fittest, the strongest, the richest, survive and the compassionate person is looked at as weak, emotional?
Compassion acts in a powerful way on the autonomic nervous system, which is responsible for all the body functions that happen automatically. Activation of the parasympathetic nervous system can be viewed as the relaxation system response, and causes a rise in the circulatory hormone called oxytocin, serving to increase our nurturing, bonding and human connection. Compassion lowers blood pressure, decreases the risk of heart disease and promotes better healing. Compassion also improves quality of life for palliative care patients and can modulate the pain people experience, by increasing endogenous opioids. Importantly, compassion is a strong help in the burnout syndrome of healthcare workers, in particular physicians. (12,13,14)
Research has shown these changes in compassion receiver patients by measuring brain wave mirror image. ( One can also measure skin conductance called electrodermal activity, by skin electrodes during psychotherapy. These generate a tracing that shows the activation of the sympathetic nervous system and psychological and emotional distress. (15) Compassion is the antidote to burnout and elevates the quality of care. As symptoms of burnout set in, compassion is decreasing.
A 2018 Mayo Clinic study found that patients need 29 seconds to state their main concern. Communicating with acutely ill patients, doctors missed 68% opportunities to respond with compassion. 17 out of 18 studies identified that empathy declined during training. A major reason was the hidden curriculum (learn by example). (16)
Science shows that hope matters and compassionate care can be a powerful help for hope. Researchers from Duke University studied coronary artery disease in 2818 patients over 2 decades and published their results in 2011. The 10 years survival was higher in patients with high recovery expectation that patients not expecting good outcomes.
(17,18) The University of Toronto identified a similar association for patients having better expectation. Belief in recovery does matter.
Compassion does not cost anything and can be learned at any age.
Emerging data on neuroplasticity has shown that the brain is actually malleable and can adapt not only to physical injury but also to new situations and new challenges. Data shows that one does not need many hours to begin to see changes in brain connection. Scientific literature shows that compassionate behaviors can be learned. Compassion makes us a better healer. Compassion is a commitment. It is something we choose to practice. In 80% of scientific studies, compassion training successfully increase compassion in health care providers.
Many people believe that successful learning is based on innate ability. People are having a fixed theory of intelligence or a fixed mind set. Other people who believe that successful learning is based on hard work training and perseverance are said to have a growth theory intelligence or growth mindset. Fixed mindset people believe their abilities are fixed traits. They dread failure because they believe that it exposes their inherent lack of ability. They do not eagerly take on new challenges because of fear of failure. Growth mindset people understand that their abilities grow through teaching effort and persistence. They do not fear failure and recognize that it is how learning occurs.
You must believe in your mind that change is possible: growth mindset. Compassion cannot be mandated and health care administrators cannot just mandate that health care providers are compassionate. It is voluntary, a growth mindset and a belief. Compassion training program increases calmness and decreases anxiety. Compassion can strengthen our personal resilience and help us coping with our challenging life. It is a health care crisis that we can easily address.
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