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Compassion in health care seems like it should be a given. Doctors enter the demanding field of medicine because they want to help people, and patients want physicians who care deeply about their well-being. So why is there a crisis of compassion in the sector today? Stephen Trzeciak and Anthony Mazzarelli, two physician scientists at Cooper University Health Care in New Jersey, examine that topic in their new book, Compassionomics: The Revolutionary Scientific Evidence That Caring Makes a Difference. Relying on evidence gathered from hundreds of studies, the authors make the case for why compassion leads to better outcomes for patients and lower rates of burnout for practitioners. Trzeciak, who is chief of medicine at Cooper as well as chair of medicine at Cooper Medical School at Rowan University, joined the Knowledge@Wharton radio show on SiriusXM to talk about bringing more compassion into the practice of medicine. (Listen to the podcast at the top of this page.)
An edited transcript of the conversation follows.
Knowledge@Wharton: How do you define compassion?
Stephen Trzeciak: Nomenclature is important in any scientific discipline, and compassionomics is no different. Researchers define compassion as an emotional response to another’s pain or suffering involving an authentic desire to help. It’s slightly different from a very closely related term of empathy. Empathy is the feeling, understanding or detecting of another’s emotions and resonating with that. Compassion takes it one step further and means taking action to help alleviate that to some extent.
Knowledge@Wharton: I’ve seen reports that say doctors often don’t feel like they have the time to provide empathy. How much does that factor into this issue?
Trzeciak: Empathy is vital because if you don’t detect or understand another’s emotional state, you’re not going to be inclined to take action with compassion to help alleviate it. A study from 2012 published in the Journal of General Internal Medicine found that 56% of physicians said they don’t have time for compassion. That was a piece of data among many that indicated to Anthony Mazzarelli and I that there is, in fact, a compassion crisis in health care. You may say we have a compassion crisis in society at large, and that’s a topic for a different day. I’m going to stay in my lane as a physician scientist and just speak to the effects of compassion.
“If you don’t detect or understand another’s emotional state, you’re not going to be inclined to take action with compassion to help alleviate it.”
There is abundant data in the medical literature showing that we have a compassion crisis in health care. Survey data shows that nearly half of Americans believe that the U.S. health care system is not compassionate. Nearly half of Americans believe that health care providers are not compassionate. This is coupled with evidence that physicians, specifically, miss 60% to 90% of opportunities to respond to patients with compassion. And more survey data shows that two-thirds of Americans have had a meaningful health care experience with a striking lack of compassion.
This is coupled now in the era of electronic health records, where there are rigorous data to show that health care providers spend more time looking into computer screens than looking their patients in the eyes. Based on all of these data, we conclude that we have a compassion crisis. But the next question is, does it matter? Does compassion really matter?
Knowledge@Wharton: I would think a lot of people would say it is a huge component not only in terms of the relationship between patient and doctor, but also in the success of the organization as well. Would you agree?
Trzeciak: Absolutely. The vast majority of health care providers, I’d say 99.9%, believe that compassion is vital to health care, in one sense — as an “ought.” We ought to treat people with compassion. In Compassionomics, we did a two-year journey through the biomedical evidence not only to test whether or not compassion mattered in a moral or ethical, or emotional or sentimental sense, but does it actually matter in a scientific sense? Is there scientific evidence that caring makes a difference for patients, for patient care and for the health care providers themselves?
That’s to your point about organizations. It is absolutely vital that we have compassion in health care because there is striking evidence in the literature that more compassion is associated with lower burnout. Therefore, compassion on the part of health care providers isn’t just good for the receiver of compassion, it’s actually good for the giver, too.
Knowledge@Wharton: How does compassion factor into Cooper and your role there?
Trzeciak: I’ll answer that in two ways — first, personal. I’m an intensivist, so I practice intensive care medicine. The way I describe that job is that I meet people on the worst day of their life. That’s what we do in critical care. I came to the realization after 20 years working in ICU that I had almost every symptom of burnout. What was I supposed to do?
There’s evidence of treatments for health care provider burnout. Most of it was not super compelling. I was aware of the evidence that more compassion is associated with more fulfillment in one’s career as well as building resilience and resistance to burnout. So, I did an experiment for myself. I’m a physician scientist. I do research. This was my N-of-1 experiment, where I was the only subject in the experiment. I tested the hypothesis that working very hard to care more and connect more would actually transform my experience, and that was when the fog of burnout began to lift for me.
Then I’ll answer the question in another way. As a leader in the organization and chief of medicine, and after curating all the data and putting it together in this book, I am aware every day of how much compassion matters, not only in meaningful ways, but also measurable ways. We are now taking a new approach and looking at that in every aspect of what we do.
Knowledge@Wharton: What does this focus on compassion mean for the business of the health care industry?
“There is abundant data in the medical literature showing that we have a compassion crisis in health care.”
Trzeciak: That’s a great question and an important question, and obviously a big question, as health care is once again at the forefront of all the headlines in the 2020 election cycle. We spend $3.3 trillion in health care in general. Where does compassion matter there? I think it’s important to break it down from what perspective. There’s the societal perspective, and then there’s the health care system perspective. One is if you’re an American, the other is if you’re a CEO of an organization. I’ll start with that one.
There is clear evidence in the biomedical literature that compassion for patients is a profound driver of business. When you ask patients what they look for in a health care provider or specifically a physician, they don’t say the technical things because they just assume that’s a given, that the doctor knows what he or she is doing. What they want is the relational aspect, and that has been borne out in study after study after study. What is largely called patient experience is a profound driver of business in health care.
But we also found that compassion communicates competence. There is a lot of research that shows that when patients are treated with compassion, they perceive the health care provider to be more competent. Clearly, you’re going to have trouble building a practice if people don’t think you’re competent.
On the other side is the societal perspective, and there you’re not so focused on revenues. There are numerous studies, most of them coming from the primary care domain and family medicine, specifically, showing that compassionate, patient-centered care with a strong personal connection with a physician is associated with lower discretionary resource use — fewer diagnostic tests, fewer referrals to specialists, fewer unnecessary hospital admissions and lower total health care charges. Our thinking is that if you spend more time with the personal connection, maybe you don’t need so many tests and referrals. Health care providers who do not have that personal connection with patients more often use tests and technologies as opposed to talking.
Knowledge@Wharton: Can you talk about compassion being part of the decision-making process in selecting a doctor?
Trzeciak: We devote a whole section of Compassionomics to this issue of the finances and the business of health care. Obviously, a big part of that is how you go about selecting a physician. There is a study of 7 million online reviews of physicians, and what the investigators found is that just over half of those reviews were focused on the personal connection, what we call the caring parts of health care, compassion for patients obviously being a cornerstone of that relationship. A minority of the reviews were focused on some technical aspects of how wonderful a physician was or not. So, when you look at what patients are looking for in a physician, as well as how they evaluate physicians, it is that relational component that is so vital to patients.
Knowledge@Wharton: Are medical schools teaching about compassion?
Trzeciak: I love that question. It’s a vital question. We talk about this whole section of the book on nature versus nurture. Can you learn compassion? I will tell you that my mind was changed as we went through this two-year journey through the scientific evidence because I used to believe that you were either wired for compassion or you’re not. It’s something in the fabric of who you are or maybe in your DNA, but it isn’t something that can be learned.
Then I saw the data. There is an abundance of data that compassionate behaviors can, in fact, be taught and learned. The key word is behavior. We’re not talking about what one believes in their mind as they care for another person, but how do they behave towards the patient and how does that effectively communicate compassion or not? This is a vital part of medical education. Historically, medical schools have always had a component on the doctor/patient relationship. But in our book, both Anthony and I believe that we have underestimated the power of compassion. We’ve thought about it in the moral/ethical/emotional sense, but we haven’t thought about it in a scientific way.
“It is absolutely vital that we have compassion in health care because there is striking evidence in the literature that more compassion is associated with lower burnout.”
Of the 430 references in the book, there are 250 original science research studies from peer review journals, so we put a lot of rigor to this. What we found is that compassion matters not only in meaningful ways, but also in measurable ways. In medical schools, what we believe we ought to do is have an awakening to the rigor that’s there if we just look at it that way. And we curated all the data in this book.
Part of what I do as a professor is interview medical school candidates. I talk to the person first before I look at any of their data, their standardized testing. I want to know if the candidate can connect with a person. Sometimes there are just incredibly warm people that I know can talk to any patients, and sometimes not. In my estimate, that’s a really big thing.
If they were not in the top of the candidates, they wouldn’t be sitting in the chair. I already know that they have incredible test scores. I already know that they aced all their classes in college. Our medical school has made some of the lists for one of the hardest schools to get into in the country because we have exceptionally high standards for that sort of rigor. I know everybody who’s a candidate sitting in the chair can do the work; then I just look at the personal factors and how they can connect with people.
Knowledge@Wharton: Do you differentiate the need for compassion with somebody who is, say, a general practitioner in comparison to a surgeon? Or somebody who works in a cancer center in comparison to the emergency room?
Trzeciak: Across different caregiver roles, there are different opportunities for compassion. For example, I’m an intensive care doctor. The majority of my patients are unconscious. I can’t actually talk to them, but I certainly can talk to their families. Depending on what caregiver role you have, you have a different opportunity to make that connection.
You mentioned surgeons. I actually think surgeons get a bad rap. Some of the most compassionate physicians I’ve ever met in my life have been surgeons. While there is a huge technical component to what surgeons have to do, for the vast majority of surgeons that I’ve met in my life, that connection with their patient is incredibly important in their mind. It’s not only for the patient to put them at ease before and after surgery, but also for them and for their own fulfillment in loving what they do.
So, there are definitely different opportunities across different caregiver roles. You mentioned emergency physicians. We recently published a paper in the journal Intensive Care Medicine in which we found an association between compassion at the point of care during a life-threatening medical emergency and lower symptoms of PTSD (post-traumatic stress disorder) 30 days later. Patients who go through medical emergencies and critical illness often come out with PTSD. We think of it as a combat-related trauma. When you go through a critical illness and an emergency where you think your life is hanging in the balance, and it is, and you have awareness of that, you can come out with psychological symptoms down the road.
What we found is that there’s an association between more compassion at the point of care when the patient is experiencing that emergency, potentially making it less psychologically traumatic. It’s very preliminary data. We’re getting ready to put in a grant to the National Institutes of Health to study this further.
“Health care providers who do not have that personal connection with patients more often use tests and technologies as opposed to talking.”
Knowledge@Wharton: Is compassion linked to the issue of readmittance of patients? If you have that compassionate relationship between doctors and patients, will patients behave differently once they leave the hospital so that they have better outcomes?
Trzeciak: Absolutely. This goes back to an earlier question you asked about costs. One of the most expensive, avoidable costs is related to something called nonadherence. We’re talking about how patients take care of themselves. They’re only in the physician’s office for a very short period of time. The rest of the time, they’re on their own. Adherence is when a patient takes their medicine as prescribed. Nonadherence has been estimated to account for between $100 billion and $300 billion of downstream avoidable health care costs in the United States alone.
In Compassionomics, we go through all the data regarding self-care. We found a signal in the data that when you care deeply about patients and they feel that, they’re more likely to take their medicine. Let me give you a study from Johns Hopkins several years ago on 1,300 patients with HIV. That’s a disease that is quite controllable, but you have to take your medicine. Researchers asked, “Does your health care provider know you as a person?” They adjusted the analysis for all the other factors that could be associated with nonadherence. They found that knowing the patient as a person was associated with the patient being more likely to believe that the therapy would work. But here are the striking data points: It was also associated with 33% higher odds of adherence to therapy, and 20% higher odds of having no detectable virus in the blood.
Knowledge@Wharton: Traditionally, isn’t it the job of the nurses to be compassionate and not the doctors?
Trzeciak: I just want to say we think it’s everybody’s job. But you bring up an important point. It just so happens that of the 250 studies described in this book, there are many more studies about physicians than about nurses. We were just drawn to where the data led us. But a nurse’s compassion is absolutely vital. When the book was launching, one of the things that we were seeing in social media were messages from nurses who said, “We think that this should be obvious.” To some extent, we do believe that there is intuitiveness here, right? Compassion does make a difference, and that’s sort of what everybody knows in health care. But where is the data behind it? That’s why we wrote the book.
Knowledge@Wharton: Can the ideas in your book be applied outside of the medical field?
Trzeciak: Absolutely. There has been a lot of interest in the principles in our book from outside of the health care field because the thread that is running through the data probably is underpinning quite a bit of the burnout, employee retention, fulfillment and well-being in other industries. We just decided to study it in the health care literature because Anthony Mazzarelli and I are physician scientists, and that’s what we do. But we believe that the lessons you learn by taking that journey through the data are things that can be applied broadly.