It should not come as a surprise that we crave compassion when ill. It is disheartening that the benefits of compassion (whatever that may mean) should need to be empirically ‘proven’, but this speaks to the current state of modern healthcare where cost control and profitability are the critical metrics of success. I recently had the pleasure of reading Compassionomics on my Kindle device whilst traveling. This seemed appropriate as the book is aimed at a non-specialist, non-academic readership enmeshed in the consumption and delivery of healthcare in the United States. Compassionomics summarises the findings of a large-scale systematic review of peer-reviewed scientific literature, conducted by the authors with the aim of collating the measurable effects of the myriad clinical interventions that they group together under the umbrella of ‘compassion’. The authors hope that this ‘tidal wave of evidence’ will convinced the reader of the power of compassion in a clinical setting. They believe, as do I, that we intuitively understand that compassion has benefits. Evidence, though, is the gold standard by which healthcare systems determines which care is recommended, provided, and paid for. In a recent essay published online in Journal of the American Medical Association (JAMA), Dr Brooke Gabster, a doctor-turned-patient, drew readers’ attention to the gulf between intuition and evidence when it comes to the role of compassion in healthcare spaces when patients are frightened and distressed. She discovers myriad spaces where little bits of compassion have the potential to heal and soothe in life-altering ways. The compassion conversation remains relevant and urgent.
Compassiononics, a neologism created by the authors, was conceived after an epiphany led Dr. Trzeciak to collate all available studies on compassion, connecting the data to determine if compassion makes a difference in measurable ways. The goal was to create ammunition for American physicians and hospital administrators to champion behaviours, language, and interventions not often celebrated or recognized within the current financial model in the US healthcare system that does not prioritize allowing time for adequate listening and communcation. This Compassionomics model appears to have significant conceptual overlap with discussions regarding the value of institutional investment in the medical humanities and art in medicine. Advocates for the medical humanities also intuitively understand the value, despite a relative dearth of scientific evidence to sway medical colleagues and administrators.
The chapters of Compassionomics employ anecdotes featuring the authors’ colleagues at Cooper Medical School of Rowan University. To give one example: Dr. Edward Viner recalls his time spent as a patient on a ventilator in the ICU, observing that specific nurses who communicated their care for him were key to his healing. After recovery Dr Viner asked his colleagues to ‘science this up’ (chapter 3). While the details of his illness are unknown to the reader, there is no doubt that the care Dr Viner experienced had a very real positive physical outcome.
Many fascinating studies are summarized, though details of the experimental interventions are often vague, making it difficult to parse what exactly is being tested under the guise of ‘compassion’. An example involves the healing of an experimentally-induced skin wound: statistically, wounds healed faster in patients who participated in the supportive versus the conflict-inducing activities that included semi-scripted conversations that had the intention of generating particular emotional responses with their spouse. ‘Enhanced compassion’, the use of specific supportive verbiage by a healthcare provider, additionally was shown to improve wound pain.
The authors highlight the work of Dr. Helen Reiss, author of The Empathy Effect (2018) and Director of the Empathy and Relational Science Program at Harvard Medical School, whose research explores the connections between empathy, psychotherapy and autonomic nervous system responses. This work provides a neuroscience basis to understand how an emotional response can bring about a broader physiologic benefit for a patient. The inclusion of Reiss’s work is meant to bolster the argument that benefit is ‘not just in our head’, but has a true physiologic and medical impact and is an important point to argue for sceptical readers based in medical or administrative fields for whom qualitative data has less resonance.
The authors emphasize that the ‘most powerful thing’ affecting health outcomes in various studies is human connection. This is a core message of Compassionomics, that compassion is a surrogate for human connection. For example, the authors cite a study (Elkin, 1989) that examined the efficacy of the drug imipramine hydrochloride for depression. It was initially reported that the drug was more helpful than psychotherapy, but a closer look at the results of the study found that the more significant variable that improved outcomes was which psychiatrist prescribed the drug. The study could not define whether the personality, communication skills, informed consent style, non-verbal communication had the most significant impact, but the data suggests that one or more of these might be the critical component. The individual physician augmented the neurochemical effects of the drug was how the results were eventually reported. As a physician, it sounds preposterous to me to hear that hugs prevent the common cold, but a study published by Sheldon Cohen in 2014 showed that people with high stress and conflict are more likely to develop cold symptoms after being experimentally inoculated. The number of hugs a person received in the days preceding the inoculation predicted whether people developed symptoms, with a suggested 32% preventative benefit to having a social support demonstrated by the hug. Little bits of human contact seem to matter.
Compassionomics attempts to convince a readership of physicians and providers, healthcare administrators and policy makers by deploying a scientific methodology that speaks the language of healthcare. It partially achieves its aims. The book defines compassion as the emotional response to another’s pain or suffering, involving the authentic desire to help, but in practice the usage of the term is overly broad, variable and sometimes self-referential. Compassion is both differentiated from empathy and later conflated with it. Interventions and techniques that aim to foster an affective or emotional bond, certain rehearsed phrasings during a clinical encounter and certain non-verbal communication behaviours become subsumed into compassion and contribute to confusion. Difficulty defining mechanisms, pathways and biomarkers of particular behaviours, and differentiating piece-parts from the whole clinical encounter is notoriously difficult, and conflating authentic, spontaneous feelings of compassion with learned behaviour modifications dilutes the evidentiary impact. Compassion is jumbled to some degree with good doctoring; engagement, empathy, strong communication and interpersonal skills combined with medical knowledge and technical skills. The general public might conclude that if they don’t personally ‘like’ a physician, their care could be compromised.
In the end, the authors present a business case for developing personal connections to drive better, safer and higher value healthcare. They have collated a broad array of data to bolster their argument that kindness, engagement and good communication have direct patient benefit. They have issued a call to action that learning compassionate behaviour and skill is possible, and that providing compassion is easy and quick. Unfortunately, health care systems are still not arranged to encourage and champion such compassion. The quotation ‘[s]how me the money’ by Rod Tidwell to launch a chapter entitled ‘Compassion Drives Revenue and Cuts Costs’ directly addresses the unfortunate reality that finances remain the true drivers in American healthcare.
The authors deserve credit for publishing a framework to critically evaluate their hypothesis. Their approach attempts to bridge the chasm between the humanities and sciences by using statistical techniques of the scientific tribe to understand and validate the activities that are often felt to be only interpretable qualitatively Because the structure of healthcare is currently determined by forces that use the language of empiricism, cost-effectiveness, value and evidence, Compassionomics presents an entry point to merging humanistic care with that language. As the American anthropologist and activist Roshi Joan Halifax notes: ‘We live in a time when science is validating what humans known throughout the age; that compassion is not a luxury; it is a necessity for our well-being, resilience, and survival.’ This exercise in translating the value intuitively felt benefits has direct implications for the medical humanities in which art, music and literature continue to struggle for a role in evidence-based medicine. For this reason Compassionomics should be a guide for practitioners and researchers in medical humanities.
Gabster, B. 2019. Resident report. JAMA, 322(17): 1653-54.
Reiss, H and Neporent L. 2018. The Empathy Effect: Seven Neuroscience-Based Keys for Transforming the Way We Live, Love, Work, and Connect Across Differences. Sounds True: Boston.
Trzeciak, S, Roberts SW, Mazzarelli, AJ. 2017. Compassionomics: Hypothesis and experimental approach. Medical Hypotheses, 92-97.
Elkin, I; Shea MT; Watkins, JT; Imber, SD, Sotsky SM; Collins JF; et al. 1989. National Institute of Mental Health Treatment of depression collaborative Research Programme. General Effectiveness of Treatments. Archives of General Psychiatry, 46(13): 971-82.
Cohen, S, et al. 2015. Does Hugging Provide Stress-Buffering Social Support? A Study of Susceptibility to Upper Respiratory Infection and Illness. Psychological Science, 26(2): 135-47.
Lara Ronan, MD is an Associate Professor of Neurology and Medicine at Geisel School of Medicine, Dartmouth College and Vice-Chair for Education in the Department of Neurology at Dartmouth Hitchcock in Lebanon, NH.
Stephen Trezaciak and Anthony Mazzerelli, Compassiononomics: The Revolutionary Scientific Evidence that Caring makes a Difference, Studer Group, 2019.