The Economic Return of Compassion

Unmessable Podcast

Dr. Stephen Trzeciak is a Physician-Scientist, TED speaker, and Professor of Medicine at the Cooper Medical School of Rowan University, who’s dedicated a large portion of his career to helping patients in the intensive care unit.

More recently, he authored the book Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference where he studies how compassion impacts patient outcomes.

At the core of his research, he asked one fundamental question: Does compassion really matter?

It turns out, it does. When authentic, it plays a big role in positively impacting patient outcomes, and I will dare to say that this finding doesn’t only limit itself to the medical field. Think of its application in the business world. Within team dynamics. How compassion contributes to company cultures and trust.

Tune in to learn about how compassion drives higher returns:

• • • What is compassion really?
    • How is compassion different than empathy (and how both play out)
    • The inter-dependency of empathy and compassion
    • How does compassion drive a measurable impact
    • Data shows we are in the midst of a compassion crisis- here’s why?
    • Knowing when you are burnt out and how to overcome it
    • The role that being present plays in driving compassion

Connect with Stephen Trzeciak:

• Linkedin
• Twitter
• Website
• TED Talk

Stephen Trzeciak’s biography:

Stephen Trzeciak, MD, MPH is a physician-scientist, Chief of Medicine at Cooper University Health Care, and Professor and Chair of Medicine at Cooper Medical School of Rowan University in Camden, New Jersey. Dr. Trzeciak is a practicing intensivist (specialist in intensive care medicine), and a National Institutes of Health (NIH)-funded clinical researcher with more than 100 publications in the scientific literature, primarily in the field of resuscitation science. Dr. Trzeciak’s publications have been featured in prominent medical journals, such as: Journal of the American Medical Association (JAMA), Circulation, and The New England Journal of Medicine. His scientific program has been supported by research grants from the American Heart Association, the National Institute of General Medical Sciences, and the National Heart, Lung, and Blood Institute, with Dr. Trzeciak serving in the role of Principal Investigator.

Currently, Dr. Trzeciak’s research is focused on a new field called “Compassionomics”, in which he is studying the scientific effects of compassion on patients, patient care, and those who care for patients. He is an author of the best-selling book: Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference. Broadly, Dr. Trzeciak’s mission is to make health care more compassionate through science.

Dr. Trzeciak is a graduate of the University of Notre Dame. He earned his medical degree at the University of Wisconsin-Madison, and his Master’s of Public Health at the University of Illinois at Chicago. He completed his residency training at the University of Illinois at Chicago, and his fellowship in critical care medicine at Rush University Medical Center. He is board-certified in internal medicine, critical care medicine, emergency medicine, and neurocritical care.

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Full Transcription:

Dr. Stephen Trzeciak: Really, we’re asking this big question: Does compassion really matter? Most people in healthcare would say, well, of course compassion matters. We have a moral imperative. There’s a duty. We ought to treat patients with compassion, and of course, I agree. Is compassion just an ought that belongs in the art of medicine, or are there also evidence-based effects belonging in the science of medicine?

Tanya: That’s Dr. Stephen Trzeciak, Physician Scientist, TED speaker, and Professor of Medicine at the Cooper Medical School of Rowan University, who’s dedicated a large portion of his career to helping patients in the intensive care unit. Dr. Trzeciak is a National Institutes of Health funded clinical researcher with more than 100 publications in scientific literature, and according to Google Scholar, his work has been cited almost 12,000 times. Additionally, he’s the author of Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference where he studies how compassion impacts patient care outcomes. Steve, how did you venture into the field of medicine?

Dr. Stephen Trzeciak: I was attracted to medicine through physiology. That was always my favorite topic coming up through school. At the same time, I was actually studying philosophy, and that’s where my interest in the humanities comes in. Fortunately, when I sat down to take the medical school entrance exam back in college, I did okay; otherwise, I’d be looking for a job as a philosopher these days.

Tanya: Which is an interesting job. You’ve been practicing medicine for 20+ years now, right?

Dr. Stephen Trzeciak: That’s right.

Tanya: You had a long part of that in the ICU.

Dr. Stephen Trzeciak: I still do, actually.

Tanya: Oh, you still do.

Dr. Stephen Trzeciak: I’m an intensivist, so I specialize in intensive care medicine. I’m also the Chair of Medicine at Cooper University Healthcare and Cooper Medical School of Rowan University. I’m the chair of the department broadly, but when I practice and take care of patients myself, I work in the ICU.

Tanya: Oh, got it. How long have you been practicing in the ICU?

Dr. Stephen Trzeciak: All in, it’s been a little more than 20 years and 17 years here at Cooper.

Tanya: Wow! You must’ve seen a few things in your day.

Dr. Stephen Trzeciak: Just a view.

Tanya: Just a few. I can imagine. I’m dying to know. What has been the most mind-blowing thing that you’ve dealt with in the ICU?

Dr. Stephen Trzeciak: The way I typically describe the practice in critical care, which is intensive care medicine, is that we meet people on the worst day of their life, patients and their families. Day in and day out is, I guess, still something to be in awe of, and it’s a responsibility. I’m grateful for the responsibility, but I never lose sight of that, that when I encounter somebody it might be my 11th, 12th, 13th patient of the day, but for that patient and their family, it’s probably or may be the worst day of their life. We just try to always be mindful of that.

Tanya: Yeah, I mean, being in the ICU and having that emotional burden, I would say, just of meeting people on the worst day of their lives but having that as a constant state for you, how has that been? I mean, do you ever get weighed down emotionally from just having to deal with one thing after the other that is so dramatic?

Dr. Stephen Trzeciak: Certainly, there can be times when it’s really heavy, if you know what I mean. There are also times when it’s just incredibly uplifting. You need to really be even keeled and strike a balance and be mindful of the fact that you’re not always going to have the outcomes that you want. You just do the best that you possibly can for people. It certainly can be taxing in some way. I think I was drawn to critical care medicine. In one sense, that’s where the action is, so to speak, in medicine. At the same time, it is my experience over 20 years or so of working in an ICU that has led me to bear witness to incredible compassion from the caregivers, especially our nurses, really, and the power that it’s had on patients and families and even the trajectory of their lives.

Tanya: You are a physician scientist.

Dr. Stephen Trzeciak: That’s right. That’s code for research nerd. That’s what that means.

Tanya: Got it.

Dr. Stephen Trzeciak: Over my 20 year career, I’ve been heavily invested in research, formerly trained in research methodology, and have conducted research in ICU patients for most of that career. It’s only been lately that I’ve really migrated and then changed the trajectory of the research program to work on what we’re currently studying now.

Tanya: What are you currently studying now?

Dr. Stephen Trzeciak: We’re studying a field that we call compassionomics. It’s really the convergence of the science in the art of medicine. For most of my early medical training, I can remember – in fact, on one of the first days of medical school, our dean told us that we were – they were going to teach us both the science and the art of medicine, as if they’re mutually exclusive and totally distinct. Specifically, what my colleagues and I at Cooper have been focused in on are the effects of compassion from caregivers on patients, on patient care, and those who care for patients. Really, we’re asking this big question: Does compassion really matter? Most people in healthcare would say, well, of course compassion matters. We have a moral imperative. There’s a duty. We ought to treat patients with compassion, and of course, I agree. Is compassion just an ought that belongs in the art of medicine, or are there also evidence-based effects belonging in the science of medicine?

Our hypothesis is that there are evidence-based effects. We wrote a book on it also called Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference. We’ve reviewed more than 1,000 scientific abstracts. More than 280 original science research papers are included in the pages, woven together with stories from the frontline of medicine so that it could be interesting to anybody. In this journey through the data as well as the new research that we’re embarking on in our research program here at Cooper, what we found is that compassion matters. Not just in meaningful ways but also in measurable ways, and so being a research nerd, what I’m interested in is the measurement. How is it that we actually find scientific evidence that more compassion, that more caring, the caring part of healthcare makes people better? Not just the people that are receiving care but the people who are giving it too.

Tanya: In terms of definition of compassion, just so that we know exactly what you’re talking about, what does that mean in your word?

Dr. Stephen Trzeciak: It’s a super important question that you ask. Essentially, it’s a question about nomenclature. In any scientific discipline, you have to have your nomenclature right so that anyone you’re communicating with understands that you’re comparing the same thing. Most scientists define compassion as the emotional response to another’s pain or suffering involving an authentic desire to help, so it’s different from empathy. That’s the word that sometimes gets confused with compassion. Empathy is the detecting, sensing, feeling, and understanding another’s emotions. Compassion goes beyond empathy, and that compassion also involves taking action.

We like to say that empathy plus action equals compassion, so if you’re a patient, or a family member, or anyone that you interact with, for that matter, what they will feel is your behavior, how you act towards them. They will feel compassion, but empathy is also super important. Of course, without empathy you’ll never be motivated to compassion. If you don’t sense or detect that another person is suffering or having pain in some way, then you’ll just blow the opportunity because you’ll miss it all together. Empathy is vital to sense the opportunity for compassion, and then compassion is the behavior. Taking action upon that to relieve somebody’s suffering in, hopefully, some sort of meaningful extent.

Tanya: First of all, what clued you into switching your entire research path and going into compassionomics?

Dr. Stephen Trzeciak: I had absolutely no intention of changing direction, to be perfectly honest. It was really an awakening for me. I’ll tell you how that came about, but I wasn’t really in the market for an awakening. Our research program was hitting every milestone for success as researchers measure them, so we were getting research grants from the NIH to fund our work. We were publishing our work in some of the best journals. I was getting invited nationally, internationally to present our research, so everything was going as planned. I wasn’t looking for any kind of a change.

Then an unexpected question from a 12-year-old turned everything upside down. That 12-year-old was my son, and one evening he asked me for help. He was in the seventh grade at the time. He said, “Dad, I have to give a talk for my class at school. I know you give a lot of talks. Can you help me prepare mine?” Of course, I thought it was an awesome father/son bonding opportunity. Little did I know what was in store.

He comes to me, and he hands me the assignment. Written on the piece of paper is the assignment for his topic. It says, what is the most pressing problem of our time, seventh grade? I don’t know what you were doing, Tanya, in seventh grade. I was not doing what is the most pressing problem of our time?

Tanya: I was, yeah, definitely not thinking about that.

Dr. Stephen Trzeciak: Yeah, so that was the assignment. I was blown away.

Tanya: It’s amazing.

Dr. Stephen Trzeciak: I couldn’t believe it, but I thought, okay, this is a mentoring opportunity. Let’s work together. He said, “I have these slides and these images and these references, so I think I’m almost there.” I said, “Hold on. Do you really believe that’s the most pressing problem of our time? If you don’t really believe it, you’re not going to convince anybody in your class.” Of course, as preteenagers do, he got real frustrated with his dad. To his credit, he went away, and two nights later he came back with what he really believed was the most pressing problem of our time through his lens of experience as a seventh grader. Now, what he picked isn’t what matters. What matters is that he really believed it. He gave a talk that not only his classmates found compelling, but he did too.

This set off in me this introspection. It was like an existential crisis for me. What I was working on in critical care and our research was really important if you happen to have that very specific disease. It was meaningful, but did I really believe it was the most pressing problem of our time (definitely not)? That set me on a journey. I had to find what is the most pressing problem of our time through my lens of experience? Of course, there is no one single most pressing problem of our time. It’s whatever you believe it is through your lens of experience.

I gave this months and months of thinking about this. What I came to recognize is, that through my lens of experience as a physician, that our most pressing problem of our time in healthcare is that we’re having an erosion of the relationship between patients and caregivers, and in fact, we have a compassion crisis. There is evidence of a compassion crisis throughout healthcare. Half of Americans believe that our healthcare system is not compassionate, and if you ask them the same question about their specific healthcare provider, they will also say not compassionate. There’s data that physicians miss 60 to 90% of opportunities to respond to patients with compassion. There’s evidence that more than one-third of physicians specifically are so burned out that they suffer from depersonalization, which is an inability to make a personal connection. In the era of electronic health records, there’s evidence that healthcare providers now spend more time looking into their computer screens than looking their patients in the eyes.

Based on all of these things and all of these data I came to the conclusion that we’re in the midst of a compassion crisis. If you think about it, when you really believe you’re working on the most pressing problem of our time versus how we typically develop scientists is that they end up working on the things that are available to them. My mentor is Dr. Jones. Dr. Jones does this, so that’s what I’m going to do, or I’m at the university of whatever, and we’re famous for this. That’s what I’m going to work on. Do they really believe that they’re working on the most pressing problem of our time, and what would everything look like if they actually did? Once I saw this, I couldn’t un-see it, and I had to put everything, all the chips in the middle of the table, so to speak, and put all of our research effort on this to test the hypothesis that more compassion is beneficial for patients and for patient care and even those who care for patients so the healthcare providers themselves.

Tanya: How long ago did you make that shift?

Dr. Stephen Trzeciak: We began curating all the data on the effects of compassion because that was the very first step. We had to know what the evidence base was. My colleague and coauthor Anthony Mazzarelli and I began to curate all the data on the effects of compassion about three years ago. We are now building an original science research program in collaboration with Brian Roberts who’s our science director in the book, which curates all the information and lays it out for the reader. It came out in May. That’s Compassionomics. Now we’re working very hard to advance the original science research program.

Tanya: First of all, I do agree that we really are in a compassion crisis, and by the way, it’s not just in healthcare.

Dr. Stephen Trzeciak: That’s for sure.

Tanya: It’s in business. It’s in customer service, I mean, even compassion for ourselves.

Dr. Stephen Trzeciak: Oh, absolutely.

Tanya: I mean, a huge compassion crisis. That’s great that you’re attacking it from the medical perspective. Patients need that more than anyone, arguably, although everybody could use it. What does the scientific evidence show about when caring and compassion is present it makes a difference?

Dr. Stephen Trzeciak: There are several different mechanisms of action. One is physiological. Patients will have physiological responses that are different when they’re treated with compassion and kindness, when they’re treated with an absence of compassion, or with even rudeness, for that matter. There is also evidence of psychological effects, which some people find intuitive and so do I. If you’re treated with compassion and you’re suffering from depression or anxiety, that can have a therapeutic effect. That’s been well documented. I mean, psychiatrists have known that for decades and decades. This is not news to them.

There are also effects and very strong associations with quality of care. People who care more in the caring part of healthcare are also more meticulous. In other words, they’re meticulous about the caring, so maybe they’re meticulous also about the technical aspects. One could argue whether or not that’s actually causation or if they happen to just run in the same direction, but I tend to believe that healthcare providers who are very concerned about consistently treating every single patient with compassion are also the types of people who make sure they treat every single patient with the best possible technical expertise. One thing I should mention is that the number one determinant of clinical outcomes is clinical excellence, so the number one determinant of clinical outcomes is clinical excellence. People will often ask me, well, would you rather have a physician who is technically very proficient or one who is compassionate? It’s a false choice. You can be both, and the evidence shows that when you have both the outcomes are you have the best possible chance for the best outcome.

The last one I’ll tell you about is one of the things I think is most interesting. Another mechanism of action is in patient self-care. If you care deeply about patients and they know that, they feel it, they are more likely to take their medicine. That has been shown over and over and over again. Nonadherence to medical therapy for patients with chronic diseases so people who don’t take their medicine, who don’t do their stick to the treatment plan or the therapy plan, that ends up in unchecked disease and avoidable complications of chronic disease. It’s been estimated that that alone, nonadherence to medical therapy in the US alone, accounts for somewhere between 100 and $280 billion in avoidable downstream healthcare costs.

If you can move the needle just a little bit in getting people to be more adherent to therapy because they know that you care and it matters to you too, not just matters to them, then it could be a tremendous savings. Of course, we’re more – I’m personally the physician interested in the human toll, but there’s a huge economic toll as well that can be affected by this, and that’s really not that surprising with self-care. Often times, people who are adherent to recommended therapy might say to me, well, I’m doing it because of her, my spouse, or I’m doing it because of him, my son. Because somebody cares about them and they know that, they’ll do it; whereas, if they feel like nobody cares, then why do it at all.

Tanya: Mm-hmm, no, absolutely. I mean, anecdotally, just even from my experience as a mother who spent 180 days in the NICU so the neonatal intensive care unit with my two identical twin girls and having gone through, I don’t know, maybe at least 40 to 50, possibly even more than that, different nurses caring for my children, I can totally see that compassion and caring leads to excellence in terms of care, which leads to better outcomes, 100%. How do we overcome nurses being burned out and the amount of hours that not just nurses, just caregivers – so burnout, depression, that numbness that you were talking about earlier, if you as a person have nothing left, that you’re running on empty, it’s really difficult, which is, by the way, most medical providers. How do you put yourself in a position to give constantly for 12 hours a day, 6 or whatever, however many days you work per week?

Dr. Stephen Trzeciak: First of all, I want to speak to one thing that you raised, and that is the nurses. Anthony Mazzarelli, my coauthor and I, we dedicate the book to the nurses that we’ve worked with. We do that because, really, they’re the experts in compassion. We like to say that we learned how to treat patients from the textbooks and the journal articles and from some of our mentors, but we learned how to take care of patients from the nurses. Nurses will often say our book was completely intuitive. They didn’t need anybody to show them the data that caring makes a difference. It’s like a duh, right? Of course it does.

Being physician scientists and research nerds, we felt the need to lay out all the data, so that’s what we did. Most of the data that has to do with burnout is actually done in physicians. That’s just the evidence base that we have available to us. Nursing burnout is definitely a huge issue. There’s just less data on it, so there was less for us to write about. I want to definitely acknowledge that the nurses on the frontlines are the ones who really teach us how to care but also are probably the most at risk for what you’re describing and just being emotionally exhausted.

One of the hypotheses that we were testing is that compassion is beneficial for the giver too, and that’s a huge part. In fact, we devote a whole chapter to this in the book. When I was going through my early medical training in medical school and in medical schools across the country, there’s this term that’s used. It’s called the hidden curriculum. It’s what you learn through socialization in medicine. It’s not what you learn in the journal articles or what’s in the textbooks, but it’s what you learn because you learned as, well, that’s how things work around here, right? One of the things that I distinctly remember learning early on in my medical school training was this notion that don’t get too close to patients because too much compassion will burn you out. I recall learning that. The challenge is, when you look at the available evidence – and Anthony and I went through 1,000 scientific abstracts, more than 200 research papers, and there was a distinct body of literature speaking to this exact question. The challenge of it is, when you look in the literature and you look in the scientific studies, there is actually essentially no data to support that.

In fact, the preponderance of scientific evidence that has been published to date shows that, yes, there’s an association between compassion and burnout, but it is actually an inverse association. What I mean by that is if it was true that too much compassion burned you out then compassion and burnout would be associated, but they’d go in the same direction. Almost all of the published studies to date have shown an inverse association. That means more compassion, less burnout; less compassion, high burnout. Some people might be compelled to infer causality there, like burnout crushes compassion. When, actually, if you look at the available evidence in totality, it’s actually more likely that it’s the other way around. It’s the people who do not build strong rapport with their patients and the families, who don’t build that bond between caregiver and patients and families, who don’t have the compassion and don’t have the fulfilling part of taking care of people. Those are the people that are the most predisposed to getting burned out under the same amount of stress.

Actually, the available evidence that has been published to date suggests that compassion may actually be protective, and it would be protective through relationships, through human connection, through the fulfillment of caring for someone and serving someone. It is that positive fulfillment that allows you to have resistance to burnout. It builds your personal reserves. It builds your resilience, and that builds resistance against burnout. Actually, the available medical literature suggests that compassion can at least be protective, and for those who are burned out, it can actually be an antidote. I can tell you that that has been my experience.

I gave a TEDx talk at University of Pennsylvania last year, and we put the story in the book as well. It’s what I call my N of 1 experiment so one study subject and one patient in the study, and that was me. After 20 years of working in an ICU, I realized I had almost every symptom of burnout myself, and I can assure you that that’s not a good place to be. What was I supposed to do? I told you I’m a research nerd. What do I do? I go to the data, and so that’s where I looked for the answer. What was I supposed to do? Yes, there were some approaches that are thought to alleviate burnout to some extent. They were all in the domain of what I would call escapism, like get away more, go on vacation more, go do yoga, go do whatever, as if the solution is just getting away from patients as much as possible and everything will be fine, and I personally wasn’t buying it. Just intuitively, I thought that the answer wasn’t in escaping, that the answer had to be something that changed at the point of care.

That is when I became aware of all the data that I was describing to you about the inverse association between compassion and burnout, and that compassion for patients can actually be protective of the caregiver through building positive relationships. I decided I was going to test the compassion hypothesis for myself. Rather than caring less, I made a concerted, dedicated effort, very intentional, to care more. Rather than pulling away and detaching, I tried to lean in as much as possible. Rather than connecting less, I tried to connect more with patients and families in my ICU, and that was when the fog of burnout began to lift for me. That is when everything really changed.

I’m sure there are a bunch of people that are listening to your podcast that are going through burnout right now. I can tell you, as you know it Tanya, as well as the people listening to your podcast, you don’t have to be the healthcare worker to be burned out. What I would suggest to you based on the preponderance of scientific evidence in the medical literature but also my truly life-changing N of 1 experiment, my recommendation is to test the compassion hypothesis for yourself. Give your compassion to others every opportunity that you have and see how it transforms your experience, but I would urge your listeners not to do it because I said so but to do it because science says so.

Tanya: How do you do that authentically? How do you switch on the compassion switch in your brain? In a situation where maybe you weren’t naturally inclined to be compassionate or as compassionate, how do you turn that around?

Dr. Stephen Trzeciak: Sure, I’ll answer that in two ways, and I think both are equally important. One is the realization that people are depending on you. For example, the head of our Heart Institute is a physician by the name of Phil Koren. He’s an expert cardiologist, and he’s just a super guy. Patients absolutely love him. When we talk about this, I ask him, “Your patients think you never have a bad day.” He says, “Well, I can’t.” He says, “Of course I have bad days. Everybody has bad days.”

When he goes to his office practice and patients maybe have been – a new patient maybe has to wait weeks to see him because his practice is so large. He realizes that he is on, on like a stage performer. Not that anyone’s acting or faking it. That person has waited that long to see him. That patient, that person deserves every ounce of compassion that he can muster, every ounce of attention. In other words, he feels a duty to treat patients just like he would want to be treated himself. I try to be mindful of that when I’m at the end of a long shift in the ICU.

The other part is that we just need to be present. What I mean by that is we’re all inundated with constant distractions. The ICU is like the most technology rich part of the hospital, so in addition to your personal mobile device, whatever it is that might be distracting or pulling you away from giving your 100% focus, you need to block that out and be present. Some people have an active practice of mindfulness, some sort of meditation approach. That’s not necessarily my approach. I believe in it. Whatever it takes for you to be fully present and block out everything else from the moment, that’s when you recognize how much that patient needs you right then, and that really makes compassion flow a lot more easily, even on days when you’re not necessarily prone to feeling it.

Tanya: I would imagine too, if you invent a new context that you can – from which to operate – so for example, this is something that came up when you were speaking. Instead of thinking, oh, what do they want from me, or what do they need from me, how can I serve them? How can I uplift them? How can I make their day better? If that’s the context – or how can I make them feel better, coming from your context? If that’s the context from which you’re operating, it changes the context of – it changes the rules of the game a little bit.

Dr. Stephen Trzeciak: It does. I mentioned presence earlier. I raise this because people might ask me, well, what is it you say, or what is it you do? Sometimes the answer is nothing. Sadly, sometimes in what I do in the ICU, there are no words. There are no words that will make the experience any less difficult than what it is, but what you can be is present.

I had a pastor friend once tell me that when he makes calls to people in the hospital, when he goes to see people in the hospital, he just likes to sit with people in their suffering. He knows that he doesn’t have the words because there aren’t any sometimes in those most difficult times. Being present is incredibly important, and specifically, it’s the assurance of that presence. Saying things to patients like I know this is a difficult time, but you’re not alone. We’re going to go through this together. I’m going to be with you every step along the way. That can be really powerful for people.

I was in the ICU recently when I was talking with a woman whose brother was gravely ill. We were still very hopeful because he was relatively young, and he was otherwise healthy before this illness came upon him. We were hoping that he would survive, and we definitely were acting accordingly. He was getting every possible therapy of the other sun – under the sun, but I had to be very honest with her that he was gravely ill. Death was probably more likely than not, but we were going to try everything we could. Obviously, that was super difficult for her to here.

At the end of our super difficult discussion, what she said to me was, “You don’t remember me, do you?” Now, when you’re an intensivist and you hear that, it’s never a good thing, right? I had to be honest with her. “I’m sorry. I don’t.” She says, “Well, I wouldn’t think you would. You see so many patients every day. It was seven years ago. I wouldn’t think you’d remember, but I was in that room right across the hall.” She points across the hall to the room in the other side of the ICU.

She says, “You and I had this very same discussion seven years ago when my mom was in this ICU, and unfortunately, she had a terminal condition. There was no hope for survival.” She says, “As difficult as that was and still is every day, there’s one thing that you will never forget,” and it was the compassion of the nurses in the ICU. When her mom was dying, they wouldn’t leave her side. They were always there for her, and they just let her know that. Even though there weren’t any words that could’ve made the situation any better, the fact that she just felt their presence and the fact that they weren’t – she wasn’t going to walk through it alone meant the world the world to her. Now, every time she thinks about it, she’s revisited by those memories. As hard as the memories of her mom are, she’s revisited by the compassion of the nurses.

Even when you think that compassion can’t make a difference because of the circumstances, the technical aspects of the care – maybe something’s not treatable or curable. Even when compassion can’t make a difference, it still makes a difference. For the patients and their families, these experiences, every time they go to remember it – and it might be every hour, it might be every day. Hopefully, as time goes by, it’s less frequently, but every time they’re revisited by the memory, they are also revisited by the compassion. It’s like an echo chamber that echoes over and over again. When I’m teaching my medical students and my resident physicians in the ICU, I teach them your compassion in this moment will be played out in these people’s minds perhaps for the rest of their life, so act accordingly.

Tanya: Yeah, no, I totally agree. As you’re talking, I’m thinking about all the incredible nurses that helped us along the way with the twins. We recently actually just visited them. We send pictures. Our twins turned 2, and so every birthday we send pictures to the whole staff. I mean, our kids had a graduation party when they left. It was one of those things.

Dr. Stephen Trzeciak: That’s wonderful.

Tanya: Yeah, they put a hat on them, really great. You mentioned that there was a compassion crisis. Did we have compassion at one point and somehow that just went to the dumps recently, or what happened?

Dr. Stephen Trzeciak: There’s research on this. There’s a meta-analysis published. It was from investigators at the University of Michigan several years back which found a decline in empathy over time amongst college-aged students. This is also compounded by when you ask middle school and high school-aged students – and there’s a Harvard study on this years ago. They asked these students what do you parents value the most, your kindness towards others or your achievements and your accolades? More often than not, they answered the achievements and accolades. There’s even one study from Pew Research which was done in 2016, and it found that one-third of patients will actually admit that compassion is not among their core values. I don’t know if we – if there was a particular moment in time when everything broke, but I can tell you that the data support that it’s not just low and has always been low, that there actually is a decline. I’m going to stay in my lane as a physician and stick with healthcare, but clearly, we’ve got a societal problem. As a father of four, it’s super concerning for me too.

There is one other thing that I wanted to mention that might be of use to your listeners. There was a paper in JAMA. Journal of the American Medical Association, one of the highest impact and most influential medical journals in all of medicine, really, published a paper on this years ago about emotional labor. For people outside of the healthcare domain, emotional labor is probably something they think about on a regular basis if they’re in customer service or in any kind of service or a helping profession, for that matter. In healthcare, it’s been a little bit new to think that we’re actually performing emotional labor. As I mentioned, with my colleague, Dr. Phil Koren, what he was doing in the office with his patients who have been waiting six months to see him is he was performing emotional labor, meaning that there’s this notion of deep acting and then surface acting. Surface acting is like faking it, right?

This is just my opinion. If you’re surface acting, meaning if you’re faking, people can detect that 100% of the time, but deep acting is different. Deep acting is when similar to what – Kelly Leonard from Second City was teaching me about this recently. Deep acting is what method actors do to get into their role, and it’s not fake. They actually get into that emotional state. The difference is that they’re just very intentional about going there. In healthcare, for example, when you realize that a patient needs you, you have to get there somehow in order to meet them, meet that patient where they are in order to meet that patient emotionally, and deep acting is where you do whatever you have to do in order to get into that emotional state and being present for your patient, connecting with them.

The way I like to think of deep acting is that we do this all the time. Anybody who has kids does this all the time. There will be times when you come home from work, and you’re tired, and you’re stressed. The last thing that you want to do – for example, when you’re reading stories to your kids at night, that emotion that you’re exuding when you read stories to your kid at night, it might not be how you’re feeling after you get home from a hard day at work. You’re stressed, and maybe you had conflict at work. Nothing’s going right, and you’re worried about this or that. Maybe your emotional expression when you’re reading the story is different from how you really feel on the inside. Are you faking it? You’re not. You’re not faking it. It’s because you love your kids, right?

That’s where you’re going emotionally because they need that in that moment, in that time when it’s story time, and so we do it all the time with our kids. We get into wherever we need to be with our emotional state to meet them where they are, and it’s not because we’re faking it. It’s because we care.

Tanya: Yes, I’m just thinking about what has caused the decrease in compassion, whether you could get there and whatever you called that, the deep acting or something like that, but you mentioned also that the care providers spend most of their time or a lot more time in front of the screens in the digital era than before. I’ve spoken with a number of neuroscientists and read a number of studies out there that might suggest that there is a decline. I’m interested in the decline of empathy in business because it affects your ability to lead people, which has everything to do with a state of being where you enroll other people to follow you and connect with the bigger purpose and align their actions to accomplish a future that wasn’t supposed to happen otherwise. That possibly the decline of empathy and, therefore, compassion – I like your equation, empathy plus action equals compassion – is potentially due to the increase in screen time. I can see that with myself. Sometimes I’m on my phone a lot. My daughter is yelling, “Mom, mom, pay attention!” It’s like, okay, snap out of it. It’s almost like an addiction to look at what’s going on out there at work, with the friends and the social media, whatever. I’m not an expert at this, but do you have any clue that that statement or those findings could be potentially true?

Dr. Stephen Trzeciak: Absolutely, you’ve hit on one of the most timely and important questions of present day in healthcare, and it has to do with electronic health records transforming the doctor/patient relationship and, in some ways, coming between healthcare providers. I don’t just mean physicians: nurses, other healthcare professionals and their patients. There was a wonderful article in The New Yorker last year by Atul Gawande called “Why Doctors Hate Their Computers.” First of all, let me just say a couple of things in favor of electronic health records, okay? I don’t want to be one of those physicians that just demonizes the electronic health record or the EHR, as we say, and then blames everything that’s bad in their day on the electronic health record. It is literally causing physicians incredible amounts of additional work. Even though it was supposed to make things simpler, it’s created more documentation, more things that take you away from the experience of connecting with patients and actually treating patients.

I do want to say some things that electronic health records do. They keep patients safer. That is unquestionable. There are many safety features built into electronic health records that tighten up many of the things that were totally loose and, quite frankly, archaic when everything was written down on paper, so that is very good. They also facilitate communication between different healthcare providers. That is really good.

One of the things that’s super bad about them and we haven’t conquered this yet is how is it that we can get them to populate themselves as healthcare providers, take care of patients through artificial intelligence or whatnot? Eric Topol wrote a fantastic book on this called Deep Medicine about how these systems could evolve so that it doesn’t take away from patient care. Have you ever been at the doctor’s office or with a healthcare provider, and you’re supposed to be talking to them, and they’re just typing into the computer as you’re talking? While that is happening, what are all the things that the healthcare provider is missing? How about the emotional cues? That maybe there’s something much deeper going on. That if they were fully engaged and present for their patient, they would detect. What does it pull out of the doctor/patient relationship that’s meaningful?

I think the answer is a lot. I think that we – the data that I quoted you earlier is that there’s rigorous data from some of the most respected institutions in America and funded by the NIH, for example, that show physicians miss 60 to 90% of opportunities to respond to patients with compassion. Much of that data was derived from studies that came before the widespread use of electronic health records. What is it now? I believe we’re missing a lot of opportunities for compassion when we’ve got our face buried in the screen rather than looking our patients in the eyes. That is the next big thing that needs to be conquered in my opinion in healthcare. We need to find a way to keep patients safe by having meticulous electronic health records. We need to find a way that we can let doctors be doctors, and let patients be patients and not let doctors or nurse – or I’m sorry. Let doctors be doctors. Let nurses be nurses. Prevent both doctors and nurses from being glorified typists who are just locked in on their computer screen.

Tanya: Hopefully, we can find a solution, or hopefully, there’s going to be a solution that’s going to come up in the technology that would allow more facetime versus trying to keep meticulous records while maintaining the patient’s safe. How do you teach compassion? Where do you start?

Dr. Stephen Trzeciak: I used to think that people were either wired for compassion, or they’re not. I used to believe it was in somebody, in the fabric of their DNA or whatnot. You’re either compassionate, or you’re not. You were born that way, perhaps, or you’re not. You’re predisposed to it, or you’re not. When you look at the data, that’s actually not true, at least not all the time. We actually have a whole chapter in the book – in Compassionomics, we have a whole chapter dedicated to the question can you learn compassion? The answer from the available literature is yes. My colleagues and I here at Cooper, we just published a paper just earlier this summer in PLOS One, which is a journal from the Public Library of Science, where we did a systematic review and qualitative meta-analysis of all the studies that have ever been published in the biomedical literature about training physicians, whether physicians in training like students, or residents, or attending physicians, training them in empathy or compassion. What we found is that there have been 52 studies, and of those, 75% of them worked. What I mean by worked is one or more outcome measure for empathy or compassion typically measured from the patient perspective got better after the training program.

Matthieu Ricard uses this analogy of javelin throwing. Tanya, if you and I went out to the field today and tried to throw a javelin, I’m sure I wouldn’t be very good at it. I don’t know if you would, right? If we went out every day and practice it, we could probably throw it a little farther. We may never get to the point where we’ll be in an Olympic javelin thrower, but we certainly can get better every single day moving farther than we did before. People may be more predisposed or not. That’s a question for other people to answer, but I do know that the data shows that you can in fact get better. The operative word is behavior, so it’s compassionate behaviors that get better. That’s what the patients perceive from their perspective, or if you’re in business, that’s what the customers perceive. The data shows that you can in fact get better.

That’s a very important concept for me. I wrote a book called Compassionomics and do compassion science research. You might think Steve must be the most compassionate doctor. The honest truth is that I am very, very much a work in progress, but I see it now. Importantly, I understand that the science says that I can in fact get better, and I am very thankful for that.

Tanya: Yeah, I mean, like anything, it’s a muscle that you develop. When you first realize that, ooh, that muscle is not very good, it seems a lot bigger of a hill to climb than when you’re not aware of it, so that’s actually great. One thing that you said that I thought was really an eye-opener and jives and actually resonates very much anecdotally is the idea that when you be – when you are more compassionate towards others, you don’t get more burnout. Actually, you feel more reenergized when you’re serving people. I can totally see that. That when I am at service of others, at the service of others, whether that be my children – and I don’t mean to serve them, like slave over them. I’m saying to really serve them as people and really stand. How can I make this person’s life better? Whether it be just jumping in a cab and asking the cab driver how was your day or whatever that is, I do feel a lot more energized. I love that that is actually supported by research. People can use this as a takeaway that – if they’re feeling tired at work even, to really show more compassion to others and shift the focus on how to elevate others, and in return, that will most likely also elevate them.

Dr. Stephen Trzeciak: Serving others is a transformative experience, and I wish it didn’t take me this many years of research until age 50 to figure this out and, also, that I’d be invited to your podcast to tell you. I see it now and, in some ways, better late than never. Now, just as I told the story, my N of 1 experiment, where I found that connecting with others more and treating people with more compassion transformed my experience and actually pulled me out of the throws of burnout, that’s been a life lesson that has been really incredible for me and something that I’m even trying to teach my kids about.

Tanya: Yeah, well, a very important lesson. Steve, thank you so much for taking the time and being here with us today and sharing all of your incredible scientific research that you’ve been doing on compassion and healthcare and, more importantly, how we can really leverage it in our own lives to feel better and to elevate people. Thank you so much.

Dr. Stephen Trzeciak: Thank you so much, Tanya.

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