The Effect of Kind Behavior
Physicians sometimes wonder how much patients pay attention to what they say and what kind of impact they have made.
The answer appears to be that a kind word and expression of concern from a physician can have a far more powerful effect on patients than was previously thought. A growing body of evidence suggests that offering kindness, empathy, or words of encouragement leads to better patient engagement, a more trusting relationship, better health outcomes, and a less stressful practice for clinicians.
Physicians often feel compassion and warmth toward patients but don't realize that they're not always expressing it in a way that comes through, say experts. A few well-placed words and actions from a physician can make a huge difference in how a patient responds, both physically and emotionally.
What Does a Physician Convey to Patients?
While empathy and compassion are often used interchangeably, they're not the same, and both are important, said Stephen Trzeciak, MD, MPH, professor and chair of medicine at Cooper Medical School of Rowan University, Camden, New Jersey. Empathy is the ability to mirror someone's emotions—feeling their pain—while compassion indicates a desire to take action, Trzeciak told Medscape.
Trzeciak says that spending an extra 40 seconds showing compassion to a patient can make a large difference in the patient's outcome and in reducing physician burnout. Trzeciak and colleague Anthony Mazzarelli, MD, JD, MBE, recently published Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference (Perfect Paperback), which explores the impact of compassion in medicine. Most of the 440 references cited in the book point to a strong correlation between kindness and better health, said Trzeciak.
"What we found through this systematic review is a very clear signal in the data that compassion matters," he said, "and that it matters in ways that are not just meaningful, emotional, sentimental, and ethical, but also in scientific ways."
Trzeciak and colleagues identified 50 potential mechanisms of action for compassion—ranging from effects on physiology, pain, psychology, and neurobiology, to health quality, experience, and patient and physician satisfaction—and 45 potential outcome measures.
They found evidence that compassion can reduce systemic inflammatory pathophysiology, leading to enhanced wound healing and better immune function. Compassion can also stimulate better patient adherence, leading to better control of disease progression and a shorter recovery time, they suggested.
Admittedly, it is an evolving science because so much of the data is observational, not experimental, said Trzeciak. But Trzeciak said he is convinced that compassion can improve health outcomes, decrease burnout, and lower the cost of healthcare.
How Does Compassion Help Health?
Researchers who have studied empathy and compassion say that kindness has a demonstrable and measurable effect.
Lauren Howe, PhD, a social psychologist and chair of human research management and leadership at the University of Zurich, Switzerland, told Medscape, "The work on empathy has shown that people who interact with more empathetic physicians have shorter durations of the common cold and have better outcomes when it comes to complications related to diabetes."
Howe led an experiment showing that patients fared better when their clinician was warmer and acted more competent; they felt worse when the provider acted cold and less competent. In that trial, all of the patients were given a skin prick with histamine. Both groups were given a cream with no active ingredients. The clinician set either positive expectations (cream will reduce reaction) or negative expectations (cream will increase reaction). Additionally, one group got a clinician who was chatty, smiling, making eye contact, called the patient by name, worked in a clean office, and gave the skin prick without hesitation. The other group met with a doctor who was focused on a computer screen, did not introduce herself, was in a messy office, and hesitated during the skin prick.
The results showed that the impact of patient expectations of the allergic response was enhanced when the clinician acted both warmer and more competent, and was negated when the provider acted colder and less competent.
Researchers concluded that clinicians could harness this psychological placebo effect—behaving more warmly and showing more care—to improve treatment outcomes.
"We see that when people have more trust in their healthcare provider, they're more likely to follow through on recommended care, they report that they are in better health, and they are more likely to be engaged in their health," Jessica Greene, PhD, professor of health policy at Baruch College, New York City, told Medscape.
How to Show Compassion in the Clinical Setting
Physicians may struggle with the balance of keeping a professional distance and the desire to connect with patients on a personal level. The weight of administrative tasks, such as the EHR, is also a factor; some physicians feel that they don't have time for compassion. Others simply don't know how to convey kindness.
"I was taught in medical school to maintain a distant objectivity," said Ronald M. Epstein, MD, director of the Center for Communication and Disparities Research at the University of Rochester Medical Center, Rochester, New York. "I very quickly found that when I entered practice, that didn't lead to the kind of healing relationships that I think patients need and want," he told Medscape.
Patients want to feel seen, to feel known.
"Patients want to feel seen, to feel known," said Epstein. "If you have no capacity to enter into the patient's emotional world, they really won't feel heard," he said. It's important to hear them to help them, he said. "If suffering goes unrecognized, obviously you can't do a very good job of relieving it," Epstein said. Epstein and his colleagues teach mindfulness to physicians in an effort to improve emotional regulation and, in turn, compassion skills.
In a Manner of Speaking
The way a clinician talks to a patient helps convey compassion—or lack of it, said Epstein. Epstein and colleagues documented and defined real instances of compassion by recording conversations between oncologists and patients.
The recordings were reviewed by a team that included clinicians and medical personnel with a communications or linguistics background. It became apparent "that compassion is not a quality of a single utterance but rather is made up of presence and engagement that suffuses an entire conversation," said the authors.
Clinicians expressed compassion through direct or indirect verbal statements that offered emotional resonance, softening of tone, or added emphasis, for instance.
They addressed suffering by making action statements such as "I'm going to help you through this," and they demonstrated compassion through personalization (treating someone as a unique individual), affirmation, reassurance, action, supplementary humor, non‐abandonment, and presence.
The conversations reflected a range of responses, from total absence of compassion to thoughtfulness. The authors concluded that it "confirmed others' extensive observations that physicians often respond inadequately to patients' suffering and re‐direct the topic of conversation away from the exploration of emotions."
Lack of compassion is particularly troubling for patients with advanced cancer "when medicine has relatively little to offer in terms of reversal of disease, but a lot to offer in terms of relief of suffering," Epstein said. "The research illustrated the paucity of compassion in a profession that espouses to value it."
Epstein said many physicians—oncologists in particular—may avoid getting close to a patient because they fear that it will compound a sense of hopelessness or burnout.
"But for me, at least, and for many clinicians, trying to distance yourself and denying that you have feelings and thoughts, and that it affects you in some way, sometimes takes more effort and is more elusive than just merely recognizing it and allowing yourself to experience that stress," he said.
What If a Doctor Is Just Not a Warm Person?
Trzeciak said it takes less than a minute to show a patient compassion. "We get this idea, when we feel hurried, that we don't have time for compassion," he said. "That's a really bad place to be."
Greene said she found that whether or not a physician believed that he or she had time to be compassionate depended on how they were already practicing. "The people who do it feel like it doesn't take more time because it's how they interact with their patients," Greene said. Physicians "who do it less think that it is definitely an additional thing to do."
Lauren Howe noted that making eye contact, smiling, and listening actively does not take any more time. Howe and her colleagues also found that being compassionate didn't take extra time. In their studies, they noticed that small tweaks in the physician's existing dialogue could make patients feel more appreciated.
An example is asking someone what year they were born in instead of asking for "date of birth." Small changes like this "could help a patient feel that they interacted with a provider who was warmer," said Howe.
Compassion also combats burnout, in part because it helps you forget your own worries, said Trzeciak. "If you have low compassion for patients and you don't make that human connection with patients, then you don't have the same fulfilling experiences of taking care of people," he said. That fulfilling experience is what helps build resistance and resilience to burnout, he added.
Is America in a Compassion Crisis?
Some experts believe that America is going through a compassion crisis. Several surveys, including one published in Health Affairs, reported that half of patients and physicians believed that the US healthcare system does not consistently provide compassionate care.
"I think that people need to feel cared about in order to feel trust; and once they trust, they're much more likely to follow through with recommendations and feel comfortable in the personal relationship," Jessica Greene told Medscape. "They need that interpersonal relationship, both to be able to express what they need to share with the clinician, and for the clinician to be able to support the patient in getting to a healthier place," she said.
"More and more research is convincing me that these traits are things that can be built—that empathy isn't something that's set in stone; it can be learned and developed," said Howe.
All of the experts interviewed for this article agreed that these skills should be taught as part of the medical school curriculum and also offered as continuing education.
More people in leadership positions—hospital CEOs, medical school deans, and policymakers—need to recognize the importance of compassion, especially as the forces of frustration continue to mount for physicians, said Epstein.
It's not clear, however, how to get institutions to recognize compassion and empathy as key patient care goals, said Howe. "It's still just thought of as this extra bonus and that clinicians aren't really given credit for what they do [regarding showing compassion]," she said.
All physicians are taught to "first, do no harm," which is generally taken to apply to the physical, noted Epstein. "But there's also a harm caused by not being present," he said.