What do patients really care about and benefit from after an ED visit? Is it your correct decision to order a D-dimer or administer antibiotics within a given time frame? Or is it how you provide compassionate care? The literature clearly shows that compassionate care and physician compassion have steadfastly eroded in medical practice, and in EM in particular, over the past 30 years – with palpable consequences. Dr. Barbara Tatham, EM colleague and educator, died of metastatic sarcoma at the age of 32 in October 2019. During her last year of life, in between surgeries, ICU stays and rounds of chemotherapy and radiation, she gave lectures on compassionate care inspired by her journey as a patient. In August 2019 we met at my summer cottage to record this podcast. We explored the evidence that compassionate care improves patient outcomes and staves off physician burnout. We discussed how compassion can be learned and applied easily and efficiently in your practice. We talked about the do’s and don’ts of compassionate care and ended with a call to action. It is my hope that, through this podcast, her voice and vision will reverberate and she will continue to champion compassionate care into the future…

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Podcast production by Anton Helman and Barbara Tatham, sound design & editing by Anton Helman

Written Summary and blog post by Anton Helman and Barbara Tatham August, 2019 and August, 2020

Cite this podcast as: Helman, A. Tatham, B. Episode 145 Physician Compassion – The Barbara Tatham Memorial Podcast. Emergency Medicine Cases. Augst, 2020. https://emergencymedicinecases.com/physician-compassion-barbara-tatham. Accessed [date]

Depersonalization, burnout and trends in physician compassion

On the front lines EM physicians face patients with extreme emotional lability, pain and suffering regularly. We take pride in our ability to withstand repeated traumatic events as humans have for thousands of years in wars and famines. Why do we do this? To protect ourselves. We use our innate ability to depersonalize after these events. We do this so we can execute a pediatric airway or thoracotomy without decompensating.

But the person in the stretcher in front of us is more than a particular diagnostic puzzle or a disposition dilemma. They are often frightened, anxious, concerned or emotionally numb. Addressing their emotional states is paramount. Depersonalization may be adaptive, but it poses a major problem to quality patient care, and specifically, to compassionate care. Given this need to depersonalize, it makes sense that observational data show that doctors aren’t very good at compassion. And the problem is compounded by the physician burnout epidemic. One of the key features of burnout is depersonalization, with an inability to be compassionate. The consequence is that we unfortunately routinely miss emotional cues from patients and miss opportunities to respond to patients with compassion. A University of Washington study found that one third of end of life discussions with families in the ICU had no statements of compassion by health care providers. A study of 1,300 patients out of Harvard found that nearly 50% of patients believe that providers in our health care system are not compassionate. When health care providers were asked about trends in compassion, about two-thirds said they have observed a decline in compassionate care in the past 5 years. The trend is similar in the UK. The NHS Foundation Trust found that there has been a widespread and striking lack of compassion from health care providers.

You might be thinking that your EQ is high and that you do provide compassionate care. Well, it turns out that we are not very good at rating our own EQ. Evidence suggests that our self-rated EQ does not correlate with patients’ ratings of our EQ. Moreover, few training programs include compassionate care in their curricula.

Compassion takes up < 1% of all communications time according to a study out of the University of Chicago on surgeons’ clinic visits. That number is probably getting smaller with the widespread use of EMRs. We are spending less time with patients and more time at the computer. One study found that internal medicine trainees spend only 12% of their time actually seeing patients. Think about it – if we spend 12% of our time at the bedside and 1% of that is devoted to compassionate care, we’re spending only a tiny fraction of our time providing compassionate care.

Physician compassion and compassionate care involves learned behavior

A common misconception is that compassion is simply “feeling bad” for the patient. Compassion is more than just empathy. It is an emotional response to another’s pain or suffering that involves a desire to help. It requires a desire to take action to relieve suffering. Neuroscience research using MRI shows that when a person experiences empathy, the pain centers in the brain are activated. However, when a person is focused on compassion, the action component with the desire to alleviate another’s suffering, a different area of the brain is activated – the “reward” pathway. Seven dimensions associated with compassion have been identified: attentiveness, listening, confronting, involvement, helping, presence, and understanding. Compassion can be understood as a behavior, and like any behavior it can be learned (contrary to the popular belief that compassion is an innate quality that one either possesses or does not).

physician compassion can be learned

The myth that compassionate care is time consuming

Some EM physicians feel that they do not have time to be compassionate in the ED. The good news is that it is easy to provide compassionate care in an efficient manner. There is evidence to suggest that when physicians spend only 40 seconds simply saying compassionate statements, patient anxiety is reduced. And when you invest time in other people, you may also feel you have more time – as counter-intuitive as it sounds – you will feel less rushed. Patients who receive compassionate care not only recover faster from the symptoms that brought them to the doctor, they also have fewer visits, tests and referrals. The proportion of these patients who are referred to specialists was 59% lower, and diagnostic testing was 84% lower in one study.

physician compassion takes 40 seconds

Physician compassion is associated with improved patient outcomes and compliance

A review in CMAJ of physician-patient communication (which included compassionate care) and health outcomes of 21 studies showed a positive association between compassionate care and symptom resolution, function, physiologic measures such as glucose control, pain control and emotional health. Even patients with life-threatening emergencies may benefit from physician compassion. A study of patients involved in motor vehicle crashes showed that compassionate care resulted in fewer PTSD symptoms. A study of surgical patients demonstrated that compassion delivered by nurses or doctors just prior to surgery resulted in patients feeling less anxious, easier sedation, a decrease in need for opioids post-op, as well as shorter hospital stay. Related to improved outcomes is the observation that the more that compassionate behavior is used by physicians, the more likely patients are to trust their advice, and the more likely they are to comply with treatment recommendations, take their medications and follow discharge instructions. Simply put, when health-care providers demonstrate the depth of their care to patients, and patients feel that, they are more likely to follow their advice.

Physician compassion is associated with decreased medical error, physician burnout and litigation 

Depersonalization is a coping mechanism for emergency physicians, but it is also one of the signs of burnout and emotional exhaustion. One study looked at the depersonalization and emotional exhaustion of 7905 residents every 3 months, evaluating them with anonymous surveys that ask about major medical errors within the last 3 months. 40% reported a major medical error at one point in time. Those that scored on the highest tier of depersonalization and emotional exhaustion vs the lowest, were 45% and 54% more likely to have a major medical error. What is just as alarming were results of a study looking at self reported incidents of suboptimal patient care from burnt out among residents, including: discharging patients just to reduce physician workload, not fully discussing treatment options or answering all questions, medication errors that were not due to lack of competence, order restraints or meds for a patient without evaluating them, skipping a diagnostic test for a desire to discharge a patient and feeling guilty about the care they gave a patient.

Physicians who scored in the highest tier of depersonalization and emotional exhaustion committed the most medical errors, and those with high empathy/compassion scores had more job satisfaction and less burnout.

Compassionate care makes us feel good because it gives us a “helper’s high” – the feeling of reward that comes from helping others. Additionally, the risk of complaints and litigation are thought to be curbed by improved physician compassion. This was eloquently demonstrated in an ED waiting room study that randomized patients to watch either a simulated physician-patient discharge conversation that included two empathic statements (that the physician recognises that the patient is concerned about their symptoms, and the patient knows their typical state of health better than a physician seeing them for the first time/they did the right thing by seeking evaluation) or one that did not. The group that watched the video that included the empathic statements had significantly less thoughts of litigation and complaints about the physician.

“If you want others to be happy, practice compassion. If you want to be happy, practice compassion.”

-Dalai Lama

 

Physician compassion is associated with lower health care costs and improved resource utilization 

In addition to rapid recovery times, fewer physician visits and tests performed, compassionate care is associated with fewer unnecessary admissions and lower total health care costs. A randomized trial of compassionate care for homeless patients in an urban ED found that compassionate care decreased repeat visits to the ED. It is not only the individual patient who benefits from compassionate care, but healthcare systems improve.

 

Practical tips to help improve your physician compassion

  • Before entering a patient room for a new encounter, leave behind thoughts of your previous patient, regroup and quiet your mind so that you can be present 
  • Thank the patient for waiting, make sure they are comfortable and begin the encounter with an empathetic statement 
  • Sit down, lean in, and smile; make them feel like you care that they are there 
  • Let the patient tell their story; patients only need, on average, 29 seconds to fully describe their main concern yet are typically interrupted after 11 seconds 
  • Look at the patient and listen to all their concerns 
  • Empower them with relevant education and involvement in their treatment plan 
  • Set expectations and explain timelines 
  • Ask if they have any questions 
  • End with a compassionate statement  
    •  “I am here with you”  
    • “We will get through this together” 
    • “I know this is a tough experience to go through,”
    • “You look so uncomfortable, what can I do to help?”

Let’s say a patient tells you that they’re “having a tough time”. Rather than responding with a so-called “terminator” response that stops the dialogue in its tracks, it may be useful to take a few seconds to explore why they are having a tough time and offer a bit of emotional support. Sometimes, key details in this dialogue that help clinch a diagnosis that has been missed by multiple doctors who have rushed through the encounter.

emcases-update Update 2020: A systematic review identified five key recommendations to promote physician presence and connection in a clinical encounter. Abstract

emcases-update Update 2024: What role does compassion have on quality care ratings in EDs? A Canadian study looking at 21 variables suggested that compassion most strongly predicted overall quality care ratings; more than, wait times, clinical communication and pain and symptom management. Full article

The enemies of physician compassion

Beware of the 3 enemies of compassion:

  1. Personal issues – bias, fatigue, home or personal issues, mental health; if these seem to be impacting you it is important to assess for possible burnout and seek help
  2. Approach Issues – listen to understand, to be empathetic; do not listen to reply
  3. Erosion – not practicing your skills, not using them, can cause you to lose them

The don’ts of compassionate care

  • Do not act like your time is more important than the patient’s; once you walk in to listen to them, do not have one foot out the door already
  • Do not use sentences that start with “at least…”; it will never come across as compassionate
  • Do not judge or criticize
  • Do not assume what your patients knows or does not know and what information they may want from you – ask them first
  • Do not assume a patient cannot understand and therefore avoid sharing information
  • Do not make assumptions; everyone has a story and you do not know what your patient’s may be
  • Do not treat your colleagues with a lack of respect or compassion; you can set a cultural example

Training for physician compassion

Compassion starts with a willingness to see someone else’s pain while recognizing and acknowledging that everyone suffers in some way – that there is a universality of human suffering. It involves the understanding that there is an emotional response to our suffering – that compassion is not simply knowing that another person is suffering; that it requires tolerating uncomfortable feelings and a desire to alleviate our suffering. Compassionate care is a set of skills that can be cultivated by each and every one of us. Compassion needs to be integrated into our training and CME.  Learning compassionate care allows us to develop our own resilience as EM docs in our demanding environment. Compassion is not simply part of our nature. We shouldn’t take it for granted. 

Try compassionate care for yourselves, your patients, your colleagues, and keep in mind some of the overall benefits we have outlined here. Then, as you feel more comfortable, model it for others, help change the culture, and if you can, start a discussion, make compassionate care talked about, known, and allow it to grow. When we act out of compassion for a fellow human being, it has profound meaning. It is a real privilege that we all have – to take care of patients in the ED and use our knowledge and skills – not just to fix their immediate problem, but to heal them. You can always find compassion amongst the chaos of the ED. Find your compassion. Cultivate it. Use it.  

“The patient-physician relationship is far more than you realize. It has an impact that lingers…and those moments, those little moments matter so much more than you realize. For the patient that is going through a lot even when they don’t look like they’re going through a lot and they look healthy like me, it’s a journey. Not one that anybody really wants to be on. Those little moments that you have can change somebody’s life. The moments where my physicians have had heart, and I can feel their heart in my care, makes all the difference. And the moments when their heart’s not there also makes a difference.”

-Dr. Barbara Tatham

Remembering Barbara Tatham: Selected EM Colleague Tributes

Louise Rang, EM physician, Professional Sustainability & Wellness Lead Emergency Medicine, Queen’s University, Kingston

Justin Morgenstern, EM physician and educator, Toronto

Alicia Cundall, EM physician, Founder, EM Global, London

Joe Finkler, EM physician, Vancouver

References

  1. American Medical Association. Code of medical ethics: Principle 1. 2001. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/principles-medical-ethics.page. Accessed on February 27th, 2020. 
  2. Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, et al. The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84(9):1182–91. 
  3. Neumann M, Edelhauser F, Tauschel D, Fischer MR, Wirtz M, Woopen C, et al. Empathy decline and its reasons: A systematic review of studies with medical students and residents. Acad Med. 2011;86(8):996–1009. 
  4. Fogarty LA, Curbow BA, Wingard JR, McDonnell K, Somerfield MR. Can 40 seconds of compassion reduce patient anxiety? J Clin Oncol. 1999;17(1):371–9. 
  5. Brown RF , Butow PN , Dunn SM , Tattersall MH . Promoting patient participation and shortening cancer consultations: a randomised trial . Br J Cancer . 2001 ; 85 ( 9 ): 1273 – 9 . 
  6. Moss J, Roberts MB, Shea L, Jones CW, Kilgannon H, Edmondson DE, Trzeciak S, Roberts BW. Healthcare provider compassion is associated with lower PTSD symptoms among patients with life-threatening medical emergencies: a prospective cohort study. Intensive Care Med. 2019;45(6):815–822. 
  7. Pereira L, Figueiredo-braga M, Carvalho IP. Preoperative anxiety in ambulatory surgery: The impact of an empathic patient-centered approach on psychological and clinical outcomes. Patient Educ Couns. 2016;99(5):733-8. 
  8. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152(9):1423-33. 
  9. Roter DL, Hall JA, Merisca R, Nordstrom B, Cretin D, Svarstad B. Effectiveness of interventions to improve patient compliance: a meta-analysis. Med Care. 1998;36(8):1138-61. 
  10. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000. 
  11. Jeffrey D. Empathy, sympathy and compassion in healthcare: Is there a problem? Is there a difference? Does it matter?. J R Soc Med. 2016;109(12):446-452. 
  12. Raposa EB, Laws HB, Ansell EB. Prosocial Behavior Mitigates the Negative Effects of Stress in Everyday Life. Clin Psychol Sci. 2016;4(4):691-698. 
  13. D. Smith, J. Kellar, E.L. Walters, E.T. Reibling, T. Phan, S.M. Green. Does Emergency Physician Empathy Reduce Thoughts of Litigation? A Randomized Trial. Emergency Medicine Journal 2016:548-52. 
  14. CMPA e-Bulletin. College complaints on the rise: Better communication can help. 2018. https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2018/college-complaints-on-the-rise-better-communication-can-help 
  15. Orzol S, Keith R, Hossain M, et al. The Impact of a Health Information Technology-Focused Patient-centered Medical Neighborhood Program Among Medicare Beneficiaries in Primary Care Practices: The Effect on Patient Outcomes and Spending. Med Care. 2018;56(4):299-307. 
  16. Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med. 2011;24(3):229-39. 
  17. Redelmeier DA, Molin JP, Tibshirani RJ. A randomised trial of compassionate care for the homeless in an emergency department. Lancet. 1995;345(8958):1131–4. 
  18. Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda: have we improved?. JAMA. 1999;281(3):283-7. 

Other FOAMed Resources on Physician Compassion

EM Cases Episode 49 Effective Patient Communication, Patient Centered Care and Patient Satisfaction

EM Cases Episode 51 Effective Patient Communication – Managing Difficult Patients

EM Cases EM Quick Hits 16 COVID-19 Oxygenation Strategies, Trauma Care, Addictions Considerations, Cardiovascular Complications and Compassionate Care

https://emcrit.org/emcrit/care-oriented-resus/

http://www.emdocs.net/empathy-emergency-department/

Justin Morgenstern, “Patient experience in emergency medicine (Graham 2019)”, First10EM blog, September 23, 2019. Available at: https://first10em.com/patient-experience-in-emergency-medicine-graham-2019/.

Dr. Helman has no conflicts of interest to declare