A doctor tends to a mortally ill child in Sir Luke Fildes’s 1891 painting ‘The Doctor.’ ART RESOURCE, NY
In 1993 I was conducting fieldwork on the Fort Belknap Native American reservation when I met an oncologist from New York City during a sweatlodge ceremony. He said he was “on sabbatical” and studying with Virgil, my neighbor and an Assiniboine medicine man who was preparing to take him on a vision quest up into the Little Rocky Mountains. Marie, Virgil’s wife, told me he wasn’t the first white doctor that had come to their trailer looking for inspiration. In the coming months I learned that this doctor had experienced a professional crisis of faith. He had “fallen in a kind of plutonic love” with one of his patients who had died and found himself ill prepared to navigate the storm of feelings that the encounter had released. But what also became clear is that he had fled medicine after working over a decade in a high stress environment that discouraged any expression of emotional empathy. He hadn’t come to the mountains to escape, he said, but to find a space where he could finally acknowledge those complicated feelings.
What role does compassionate care play in the well being of medical professionals?
The University of Notre Dame’s Well Being at Work Program’s research is expanding by centering on the well being of healthcare workers. In particular, direct care workers who work on the front lines of primary and preventive medicine. We are interested in parsing out the conditions that empower a healthcare worker to flourish, even in contexts where resources are limited. The research team wants to know the mechanisms that create such flourishing and whether and how they can be replicated and adapted to various settings. But first we need to understand the culture of healthcare organizations; their taken for granted system of beliefs, norms, and practices; style of leadership, mission philosophy as ideal type (something to strive for) and reality (daily practice).
We need to understand various healthcare cultures that are in states of crisis, measured by poor patient satisfaction ratings and low worker engagement that result in high turnover. According to one survey of 482 U.S. healthcare H.R. employees at the managerial level or higher almost half (49%) of healthcare workers were viewed as not being fully engaged (Cornerstone 2014). Lower patient mortality and infection rates were associated with higher degrees of nurse satisfaction and engagement according to a Gallup study (Paller and Perkin 2004).
Increasingly there is mounting research to support the correlation between healthcare worker engagement and patient satisfaction pointing to the reciprocity between doctor and patient (Harmon and Behson 2007, Heskett et al. 2008). The U.S. Joint commission on the Accreditation of Healthcare organizations linked healthy workplaces to high-quality care over a decade ago: “A healthy workplace is one where workers will be able to deliver high quality care and one in which worker health and patients’ care quality are mutually supportive. That is, the physical and emotional health of workers fosters quality care, and vice versa, being able to deliver high-quality care fosters worker health” (Eisenberg et al. 2001:447).
Kleinman became the primary caregiver for his wife, his “soul mate”, after she was afflicted with a form of Alzheimer’s.
Harvard psychiatrist Arthur Kleinman has long recognized the significance of the symbiotic relationship of the healthcare encounter. In the prologue to Patients and Doctors by Jeffrey M. Borkan, Kleinman writes, “…We want to document that we are doing something whose importance lies in its intersubjective meaning, that presence of shared meaning lends a sacred quality to the medical calling…” “Presence”, he recently told a group of medical students from Rush and Western Michigan Universities, “is inherent in those who are ‘called’ into their work from a private to a public space of caretaking. Those who enact ‘presence’ are energized. It’s what makes care non-mechanical, gives care a vividness, a fullness…”
And whether intersubjective compassion and caring works through “mirror neurons” or as placebo or even through the mitigating factors of the “halo effect”, the benefits of empathy in medicine has translated into a host of measurable outcomes including higher rates of compliance, physiological evidence such as bolstered immunity and a decreased need for pain medication, and higher patient satisfaction ratings.
Scholars tend to agree that the ability to recognize and communicate an understanding of a patient’s concerns and experiences (cognitive empathy), benefits patients. But there is less consensus about whether the emotional response a physician may feel in response to encounter with a patient (affective empathy) benefits their mutual well being. Many healthcare providers feel that too much affective empathy can lead to “compassion fatigue” (a.k.a. burnout), and that a certain professional distancing is necessary in order to avoid it.
However, a recent survey of 7500 practicing physicians showed that doctors who reported feeling concern for their patients also reported more job satisfaction (Decety and Gleichgerrcht 2013). This suggests that developing a flexible emotional intelligence that can navigate through intense encounters combined with performative acts that affirm a patient’s humanity (active listening, non clinical touch, eye contact) could improve the well being of both medical professional and patient, and that disengagement from intense emotions is not the answer.
What is often framed as care-worker “compassion fatigue” may actually be an organizational ecosystem that hinders the ability for care-workers to actually perform “intrinsically motivated” emotional care acts. What blocks an empathetic understanding of patient concerns could be a system of daily tasks and schedules, “pressures, tensions, anxiety, demoralization, dissatisfaction, frustration, feelings of guilt, reduced support and supervision (Aronson 1996), and, for those workers whose daily encounters involve witnessing grave injury and death, “complicated feelings surrounding the grief process” (Jones 2008).
Dr. Loren Hamel, C.E.O. and President of Lakeland Health Care, wants to find a way to “hardwire compassion across his organization.” In 2013 hospital patient satisfaction rates hovered around the 35th percentile, so he decided to try something different and designed the “bring your heart to work” campaign.
Essentially workers at all levels are encouraged to share personal anecdotes and stories with patients, to connect with them on a personal level, and actively listen to their needs and concerns. Using the framework of “Who, What, and Why” staff are asked to introduce themselves to every patient (who), communicate what they are there to do (what), and explain the reason for it (why). HR managers are paired with each patient care department to attend staff meetings and rounds throughout the week to increase employee engagement on these techniques, and thereby increase patient satisfaction.
Hearts are placed on nametags each time a patient reports that they’ve emotionally connected with a worker. At the end of each day workers share stories about how they touched their patients’ lives and in turn were “touched” themselves. Hamel recounts one story he heard on rounds of an African-American nurse who confronted a man who was out of control after learning his wife was dying. The security officers let her pass and she put her hand on his shoulder and asked if he needed a hug. He wept in her arms for twenty minutes.
Hamel explains the context that precipitated his interest in bringing “heart” back to the healthcare workplace. “I was concerned with three main challenges in our field,” Hamel says. “Healthcare is one of the most memorable dramas. Every day we deal with life and death but inevitably it becomes routine. How do we avoid this? Second, patients and their families struggle to understand what we are doing to provide care but more importantly, why we are doing it. We need to do a better job in understanding their needs and explaining why certain interventions and treatments are needed. Finally, the crisis of healthcare has beat creativity and innovation out of the industry. We have to create a space for passion in our work.”
After launching his campaign, within 90 days, patient satisfaction reached the 95th percentile across three hospitals. While Hamel expects these results to peak and valley, the implications are encouraging. Still, he wonders about their replicability. “How do you standardize a smile? How can you build a culture that supports it [empathic and passionate caregiving]? But,” he says with twinkling eyes, “if you can build a culture of compassion in medicine, well that beats strategy, rules, policy, procedure… We could measure its success through lower rates of turnover, higher rates of productivity…”
Interestingly, Hamel says that the group that struggled the most with his campaign to practice empathy was doctors. They resisted using the scripts Hamel created to guide medical professionals in their interactions with patients that used “I” statements: “I am here today because I care about your health…” Hamel says, “Some admitted, ‘I’m not up to this…letting people know how much I care.” He watched them awkwardly perform embodied acts of caring in simulation labs and realized that while transmitting empathy may be simple (involving acts such as sitting down, sustained eye contact, non clinical touch, waiting 2-3 seconds after each comment or statement, and smiling), it is not always intuitive. “We are going to keep trying,” Hamel says.
Recently a (first year) surgeon shared with me that he could not recall compassion or empathy being a meaningful part of his medical training. He wondered, given the all-consuming intensity of the technical training alone, how developing emotional intelligence could be incorporated into the curriculum. Ellen Lerner Rothman’s book White Coat: Becoming a doctor at Harvard Medical School (1999) documents the rigors and exhaustion that is part of this professional training. Rothman focuses on the doctor-patient relationship and recounts her self-doubt and unease with which she approached cadavers, conducted her first psychiatric interview and initiated her first pelvic exam. She ultimately found her calling as a pediatrician. But what of doctors who feel stuck in environments that remain high-stress and among colleagues who are chronically disengaged? I mentioned a recent news story that seemed to flag a culture in crisis: a defamation lawsuit that made headlines where a patient was awarded $500,000 after he recorded his anesthesiologist and other medical staff insulting him (she said she wanted to hit him and joked he had a STD) during his colonoscopy. The surgeon shrugged and said such scenes were commonplace.
The case for training doctors who are both technically and emotionally skilled and intelligent has produced some reforms in medical education. New scales in the MCATs, the admission test for medical school, seek to filter out those who lack the psychosocial skills essential for compassionate caregiving, and assess cultural competency and aptitude for holistic diagnosis (gauging how a patient’s background, psychology and experience impacts their health). In addition to altering the MCATs, Darrell Kirch, president and C.E.O. of the Association of American Medical Colleges (AAMC) and his team is trying to more accurately measure applicants’ reactions to patient-doctor scenarios including how practitioners interact with patients from different cultural backgrounds, as well as assess how medical professionals personally respond to stress. For according to many neuroscientists, it’s not the capacity to discern and process emotions in the workplace that is the problem, but poor stress management.
To some degree, there is a consensus among researchers that empathy can be taught so the medical training itself may be the larger issue. An often-cited study shows that empathy declines when students start seeing patients, in the third year of residency (Hojat, et al, 2009). And another has shown that doctors in practice longer are more disengaged and make less accurate diagnoses because of it. (Affective empathy has been linked to more accurate diagnoses and better patient health outcomes because patients disclose more of themselves to doctors they feel are genuinely concerned about them.) What is happening to cause this progressive disengagement?
Stressors CNAs commonly cite when they leave their positions are: unfavorable staff: patient ratio, physical exhaustion, low pay, feeling unappreciated, dissatisfied with supervisor, unable to advance, unable to provide quality of care, uninspired, and compassion fatigue (Mickus, et. al. 2004). What matters most to medical employees in a 2008 study was that management cares, listens to and appreciates them, helps with stress and “compassion fatigue”, the workplace is safe, and they have “consistent assignment” when it comes to patients. The importance of relationships as both a potential barrier and facilitator to well being is striking in this data.
Perhaps it makes good sense then to, following Hamel’s example, create an organizational culture around compassion that equips medical professionals with the tools and supports needed to offset the stressors of the workplace and a space to navigate through the emotional landscape of caring work. This may include training in reflexivity (offering classes with readings that prompt a discussion of the nature of suffering in illness and how it impacts both doctor and patient), mindfulness meditation, which helps workers to discern affective from cognitive empathy and manage their emotions and relationships effectively without disengaging, and organizing peer support groups.
According to one anonymous medical resident and writer of a popular blog, narrative medicine and the practice of therapeutic writing, even 15 minutes a day, offers another outlet, a way to embark upon the practice of medicine in a coherent, calm, and dispassionate way without slowly getting lost in cynicism or indifference. Inspired by the work of poet-physician William Carlos Williams born in 1883, the resident writes of how to live within the paradox of being a scientist-artist:
As a physician, we are constantly required to maintain our calm…We must distance ourselves enough from the human condition in order to diagnose and treat objectively, and this often requires a certain degree of reticence or repression. On the other hand, the primary goal of an artist is to express – passion, imagination, memory…The world of medicine is one of tragedy and miracles. Physicians witness death, but we also witness survival, birth, and moments of deep joy and gratitude…we return to our patients – our energy source – who inspire out poetry. This is one of the aims of the artist: to capture sparks in the ocean of humanity, to create from them a flame, and to give this flame back to the vast waters from whence they came in a new and preserved form, so that we can better understand and appreciate our collective existence.
Aronson J, Neysmith SM. “You're Not Just in There to Do the Work”: Depersonalizing Policies and the Exploitation of Home Care Workers' Labor. Gender and Society. 1996;10(1):59–77.
Eisenberg, J.M., C.C. Bowman and N.E. Foster. 2001. “Does a Healthy Health Care Workplace Produce Higher-Quality Care?” Journal of Quality Improvement 27: 444–57.
Harmon, J. and S.J. Behson. 2007. “Links among High-Performance Work Environment, Service Quality, and Customer Satisfaction: An Extension to the Healthcare Sector.” Journal of Healthcare Management 52: 109–24.
Heskett, J.L., W.E. Sasser and J. Wheeler. 2008. The Ownership Quotient: Putting the Service Profit Chain to Work for Unbeatable Competitive Advantage. Boston, MA: Harvard Business Press.
Jones, S. H. (2008). A Delicate Balance: Self-Care for the Hospice Professional. self-care plan for hospice workers. Aging Well, 1(2), 38.
Mickus, M. C. Luz and A. Hogan. The Recruitment and Retention of Direct Care Workers in Long Term Care (2004) Michigan State University
 For methodology and survey questions and results see: http://go.cornerstoneondemand.com/2014-Healthcare-Survey_Appendix.html
Lakeland uses the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) initiative guidelines to uniformly measure and publicly report patients’ perceptions about aspects of their inpatient care including communication with docs and nurses, responsiveness of hospital staff, pain management, hospital environment and discharge information. The survey is central to the Centers for Medicare and Medicaid’s Value-Based Purchasing Program (VBP), which encourages hospitals to provide high quality care and increased patient satisfaction through financial incentives.