The Joy of Giving: Stephen G Post

Compassionate Medical Care Benefits Professionals, Patients and Students and the ‘Bottom Line’.

To be optimally beneficial for patients, every physician without exception should be both technically excellent and practice with compassionate care. However much the technical advances in medicine are beneficial to patients, no one who is ill should have to suffer the indignity of a technically competent but uncaring doctor, nurse, or other staff member. Good medical practice has been perennially captured in the phrase "the art of medicine," which combines both scientific-technical knowledge with humanism, defined as the physician's interest in and respect for the patient as a person experiencing illness. Too many patients experience de-humanizing and impersonal treatment, so much so that this is now a crisis in healthcare systems, proving destructive not only for patients, but for professionals, families, and the systems themselves.

That compassion should be an essential quality in optimal medical care constitutes universal and perennial wisdom in medical ethics. The oft-quoted Dr. Francis Peabody of Harvard wrote nearly a century ago, "The secret to the care of the patient is in caring for the patient." In the absence of compassion, patients are dissatisfied and professionals lament a loss of meaning and gratification in their work. Healthcare systems that gain reputations for inhumane care are unable to compete and lose revenue. For the most part, the solution lies in the small acts that show care. Good is in the details, and we must all accept that we are role models.

The care of the patient is both a science and an art. It is on the one hand the competent application of science; on the other hand it is the art of being attentively present to the patient in a manner that facilitates well-being, security, treatment adherence, and healing. Compassionate care is the essence of this art. What does "compassion" add to "care"? It adds an element of stronger affective response and deeper awareness of the concrete reality of the patient's "illness" experience. Depersonalization and dehumanization often leave patients feeling like "the kidney in room five." Nevertheless, a truly "healing relationship" that manifests emotional and social intelligence in response to illness will always remain central to good clinical outcomes. By "illness" we mean the subjective experience of disease as it interweaves with meaning systems, social networks, hopes, emotions, and values. Every patient has a story or "illness narrative" that needs to be respected; no patient is a mere biological puzzle to be "figured out." It's the loss of care in its most basic sense that is currently being singled out across the United States as a pressing ethical concern not only of patients, but of physicians and other healthcare professionals.

Bernard Lown, MD, one of the greatest cardiologists of our time, the inventor of the defibrillator, and recipient of the Nobel Peace Prize for founding and developing International Physicians for the Prevention of Nuclear War, wrote a classic book is entitled The Lost Arts of Healing: Practicing Compassion in Medicine (1996). It is a powerful statement about how compassionate care, often in the form of attentive listening, creates a "healing relationship"with patients that improves diagnostic clarity, patient outcomes, patient adherence with treatment, and brings immense gratification to the professional as well. As a cardiologist, of course, Lown is constantly aware of how closely protracted negative emotional states are associated with stress and heart disease. Thus, he views the physician-patient relationship as being as important as any technical medical intervention, and sometimes more so. His underscores how many times his diagnoses based on careful listening in a caring mode were more accurate than those of colleagues who centered their assessment on various tests but did not connect, affirm, and listen to patients. As Lown describes, it is impossible to treat a patient optimally without the basic "care" that allows for positive emotions to displace anxiety or hostility, which in turn influence healing processes within limits as is now scientifically understood at the levels of neurology, immunology, and endocrinology. Thus, it behooves us to reflect on why treating patients with compassion matters based on the best contemporary science.

In all healthcare systems, we ought to aim for a culture of compassionate care in which patients will not experience humiliating insensitivities or rudeness, but rather compassion, respect, reassuring manner (appropriate etiquette, dress, speech) hospitality & attentive listening; interactions with patients are uniformly recognized as having the significance of any important clinical intervention; physicians, nurses and all staff will find patient care more gratifying and meaningful; benevolent and respectful interactions between members of the healthcare team will be understood as establishing the secure base from which the compassionate care of patients unfolds; and the clinical learning environment inspires students with a pervasive ethos of compassionate respect, and eliminates their complaints of patient and/or student maltreatment.
Four Beneficiaries of Compassionate Care

There are four potential beneficiaries of compassionate care in the healthcare setting:

FIRST, clinicians, nurses, residents and other staff benefit. Jerome Groopman, MD, a great Harvard University doctor and author, wrote, "The entire compassionate dimension of medicine, which is really key to the profession and which is so gratifying - all of that is threatened, severely threatened, if not erased, when you are put in an environment where you are constantly hectored around money and efficiency and making sure that time is minimized with patients in delivering care, in order maximize revenue" (Groopman, 2009). The compassionate care, then, that is so uplifting and meaningful for the doctor is denied them unless they truly make the effort, which indeed they can, to practice medical compassion rather than medical disrespect. We know some hard facts about how the stifling of compassion harms physician morale: 87% of physicians who report erosion in enthusiasm for medicine (58% of 2,608 surveyed nationally in the US) attribute this loss to the inhibition of empathic care (Zuger, 2004).

Clinicians' satisfaction with their relationships with patients can protect against professional stress, burnout, substance abuse, and even suicide attempts (Shanafelt, 2009).

Up to 60% of primary care clinicians report symptoms of burnout, defined as emotional exhaustion, depersonalization (treating patients as objects), and low sense of accomplishment. This is strongly associated with poorer quality of care, patient dissatisfaction, increased medical errors, lawsuits, and decreased expressions of empathy. Substance abuse, stress-related health problems, marital and family discord, and automobile accidents are among the documented consequences for physicians. Participation in a "mindful communication program" (didactic material, formal mindfulness meditation, discussion) consisting of 8 weekly 2.5 hour sessions, plus one all-day session,was associated with short-term and sustained improved in well-being and attitudes associated with patient care (Krasner, et al., 2009).

It is not the case that most professionals do not want to care about patients, but they become very task oriented in an environment where speed is praised and rewarded, and as a consequence they can lose sight of the patient as a person unless they are both self-aware and intentionally care-full. If they lose the deeper meaning of their professional lives, many will eventually suffer adverse consequences. It takes considerable resolve to carve out the space for compassionate care regardless of environment, but in the end, doing so involves relatively small purposeful acts that change the emotional and social quality of an interactions so as to allow greater salugenesis.

There is a certain humility involved is carving out this space. Humility requires unflinching self-awareness, empathic skills, and gratitude for the privilege of caring for sick persons (Coulehan, 2010).

Small acts take many forms. A simple question or comment does wonders, e.g., "This must be pretty tough on you yes?" "How are you handling this and do you need some help?" "It's natural to feel pretty overwhelmed at time like this." We hope to have a cultural affirmation at our medical center as follows: Whenever I interact with any person at Stony Brook University Medical Center, without exception, I treat them with respect, compassion, hospitality and good manners. Small Acts Show I Care.

SECOND, medical students experience demoralization and disenchantment when they encounter a clinical environment that is dehumanizing and uncaring toward patients or themselves as learners. One can surmise that the same resident or other clinician who is rude and abrupt with patients is so with students. Medical students know bad role modeling when they see it, and we work to inoculate them against such things through discussion groups and encouragement, recognizing that no clinical environment is without its faults. However, at the same time, everything possible should be done to enhance the student experience through a commitment on the part of institutional leadership to expect acknowledge, and reward clinicians who are good role models (i.e., manifest compassionate care of fellow professionals, team members, patients and students). A cross-sectional survey of all 2,682 medical students attending seven US medical schools in the spring of 2009 showed that those students experiencing "burnout" (about half as assessed by the Maslach Burnout Inventory) had less concern about physician responsibility to society, and were less connected with their initial caring motivations (Dyrbye, 2010).

Good role modelling is essential for patient and student wellbeing, and as always, good is mostly in the small details of life. It is generally assumed that compassionate care is learned through observing good role models in the clinical setting. However, this dimension of good patient care may be sometimes de-emphasized or even trivialized in the existing clinical climate, as had been widely highlighted (William T. Branch, et al, 2009).

Third, patients benefit. The drive for human connection increases greatly during times of major distress and serious illness, and this is intensified in the depersonalized environment of a hospital room. The presence of a compassionate clinician is a gift in and of itself that can achieve as much for patients as a great many medicines, or even more.

THIRD, patients do better. When doctors are compassionate, they achieve earlier and more accurate diagnoses because the patient is better able to divulge information when he or she feels emotionally relaxed and safe (Lown, 1996). Moreover, there is more efficient treatment planning and patient adherence to that treatment in a time when as much as 30 percent of every American dollar spent on healthcare is related to poor self-care or compliance (Levinson, et al., 2000). In essence, patients can care more responsibly for themselves they sense that they are cared for by their doctor.

Considerable research suggests that people who feel compassion are typically are more secure and experience an emotional safe-haven as a result. Emotional states, in turn, do impact rate of healing, and several studies show that hostile emotional states in patients delay healing. In one study 42 married couples were fitted with a suction device that created eight tiny uniform blisters on their arms and allowed for fluid extraction. Each completed stress questionnaires and interviews. It turned out those couples with high levels of hostility needed two additional days for wound healing. High hostiles healed at 60% the rate of low hostiles. Blood samples showed one cytokine - interleukin 6 - increase 1.5times in high hostiles (Kiecolt-Glaser, et al., 2005). Furthermore, a review of 21 studies related quality of physician-patient communication with increased physical functioning, emotional health, and decreased physical symptoms of pain in patients (Stewart, 1995). Studies of patients in end-of-life care show a strong association between the undermining of dignity and depression, anxiety, desire for death, hopelessness, feeling of being a burden on others, and overall poorer quality of life. When "dignity therapy" is applied, in which dying patients are asked about what means the most to them in life and what they would like to be remembered for, 76% reported a heightened sense of dignity, 68% reported an increased sense of purpose, and most reported an alleviation of stress and other benefits (Chochinov, et al., 2005, 2008; Chochinov, 2007).

And today, we are not paying enough attention to this key ingredient to patient outcomes. As Edward Hallowell, MD, has opined,

"What's in jeopardy in medicine - for a host of reasons - is the human connection between doctor and patient. There are doctors in training now who do not want to do the physical exam; they just want the lab tests and the echo-cardiogram on a heart patient, for example. But the laying on of hands is a powerful tool in establishing trust and healing. Doctors, patients and insurers alike should work to recreate the familiarity, the warmth, the trust, and the friendly alliances that used to define patient-caregiver relationships. If the health care profession would rediscover the power of human relationship, we could bring about the kinds of lifestyle changes that would reduce disease big-time." (2010)

FOURTH, when medical centers are able to create a seamless culture of compassionate care through new employee interviews and annual training, through explicitly developing expectations and reward systems for all staff, and for including this dimension of care in educational endeavors, they will do better at the level of the economic bottom line. The new HCAHPS (Hospital Consumer Assessment of Healthcare Providers & Systems) questions ask patients if they have been treated with care and respect, were communicated with well and had things explained to them, and felt responded to adequately by nurses, doctors, and other staff. These 21 questions are now required for any healthcare system receiving Medicaid or Medicare reimbursements. In the months ahead, as much as 30% of this reimbursement will be in part determined by HCAHPS scores. In addition, money can be saved because patient adherence to treatment will rise, professional and other staff will find work more meaning and gratifying, and patient satisfaction will rise so as to create reputational gain. every healthcare dollar is associated with patient non-adherence.

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