073: The Missing Element

In This Episode: The medical profession is starting to realize that it’s been missing a very important element of patient care. It’s likely that you’ll be very surprised to hear what it is, but then when you think about it, it’ll make total sense — and you’ll be mad that you didn’t get it.

073: The Missing Element

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Show Notes

  • Help support Uncommon Sense: — yes, $5 helps!
  • The story about Rosaura Quinteros, who helped save Col. Jason Denney, which brought me to this subject.
  • Dr. Trzeciak’s  TEDx talk is embedded in the transcript.

Transcript

Welcome to Uncommon Sense. I’m Randy Cassingham.

What’s the biggest problem in healthcare today? I mean in the actual practice of healthcare, not the cost or doctor shortages, but what medical professionals do on the job. I suspect most healthcare providers would probably say “burnout” — they have too much to do, too much paperwork, too much administrative duties, and thanks to that doctor shortage, a never-ending line of patients needing care, but they’re so busy there’s never enough time to provide all the care that’s needed.

Enter Dr. Stephen Trzeciak. He’s not just a professor of medicine at Rowan University in Camden, New Jersey, he’s the Chairman and Chief of Medicine at Cooper University Hospital. He’s board certified in internal medicine, emergency medicine, critical care, and neurocritical care, all particularly heavy-hitting specialties. He works as an intensivist — the doctor who treats patients in intensive care. People only get admitted to the ICU when they’re critically sick or injured, so he has to be able to deal with it when, despite all his efforts, many of his patients die anyway.

So it’s probably no surprise that with all of that, he was burned out.

Trzeciak says that the typical “treatment” for burnout is to get away for awhile — detatch from the job, go on vacation. He said he felt intuitively that detachment was probably the wrong thing to do. He probably noticed that detachment didn’t help him, and didn’t do much for his colleagues, either.

Meanwhile, he says, we are “in the midst of a compassion crisis.” He’s not talking about sympathy or empathy: he says scientists define compassion as “an emotional response to another’s pain or suffering involving an authentic desire to help.” Sympathy and empathy are “the understanding components,” but compassion involves taking action.

Dr. Trzeciak tells the story of a 2007 highway crash in Sweden: two buses collided head-on. Amazingly, only six people were killed; 56 were saved. Researchers followed up with those 56 people five years later to ask what they specifically remembered of their ordeal. Two things stood out as their strongest memories. The first thing, no surprise: pain. The second thing: a lack of compassion from the people who cared for them during their hospitalization. Besides pain, that’s the biggest thing they remembered. Not fear, not the impact on their families, but rather that the doctors and nurses just didn’t seem to care.

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But, Dr. Trzeciak continues, the big question is, “Does compassion really matter?”

Being a research geek, he dove into the studies: there are a lot of studies about compassion in a medical setting. He reviewed more than a thousand study summaries, and read in detail the studies that stood out to him — around 200 of them. He found that two-thirds of patients surveyed by researchers said they could think of a medical encounter where they felt no compassion at all from their doctor. I’m frankly surprised that number isn’t higher!

As he read study after study, it was obvious they formed a very strong conclusion: compassion does matter — a lot. Not just because of the moral imperative, but it turns out that the effect on healthcare providers of expressing compassion for their patients is significant: it leads to more attentive and effective care, which obviously benefits patients. In fact, studies of compassion find the patients have much better medical outcomes if they feel their doctors actually care. When doctors feel compassion for patients, they’re less robotic: they order fewer tests, make fewer referrals to specialists, order fewer unnecessary hospitalizations, and, I’d guess, make fewer mistakes — all factors which significantly lowers the cost of care.

This doesn’t mean that doctors and nurses have to spend an hour looking deep into your eyes to make sure you know they care. So then the obvious question is, how long does it take to provide a “meaningful expression of compassion” — the amount of time it takes patients to say yes, they felt their doctor treated them with compassion; they felt their doctors cared what happened to them. So researchers studied that, too.

The results are stunning: it only takes 40 seconds to let the patients know their doctor understands that this is a scary and stressful time, that he or she will work hard to get them through it, and will be there for them. They also encouraged patients to interrupt to ask questions if they’re confused or unclear. All that actually only took 35 seconds in the study. At the end of the appointment all of that is reinforced with the I’ll be there for you part, which accounts for the other 5 seconds.

Johns Hopkins University came to that conclusion after studying cancer patients having their first consultation with their new oncologists, about the most stress-inducing doctor’s visit someone can have. They used rigorous study protocols: a randomized, controlled trial with actual doctors and patients. And the answer was just 40 seconds! What doctor really doesn’t have 40 seconds to connect at a human level with their patients? Especially when it leads to significantly improved outcomes? That’s what they’re there for: the best possible outcome! It’s their job!

But the real clincher is, the doctors benefit too, with reduced stress, better health, and less burnout. That’s the kind of win-win we often see when Uncommon Sense is used to drive change.

After reading that study, Dr. Trzeciak realized that maybe that was a better “treatment” for burnout — instead of detaching, maybe they should actually “attach” more by making it a point to spend that 40 seconds to convey compassion purposefully. Maybe, he thought, doctors could benefit as much as the patients to ease their burnout. He didn’t find a study for that, so he did his own study, using just himself as a test subject, and making sure that he spent at least 40 seconds of each patient visit to engage compassionately with them.

And the more he did it, the less burnout he felt. He says it changed his life. And, by the way, it helped his patients too: outcomes improved.

What brought my attention to Dr. Trzeciak wasn’t finding an article about him. It was an article about Rosaura Quinteros, who works at the Dr. P. Phillips Hospital in Orlando, Florida. One of the patients she visited daily was Jason Denney, a 52-year-old U.S. Air Force colonel who was near death from COVID-19. He was in such bad shape that a priest even gave him last rites.

Maybe because of his military background, Denny had refused sedation, and refused a ventilator to help him breathe. He put his energy and attention into surviving for the next 5 minutes. And then the next 5, and the next 5.

Quinteros was in a group of hospital employees who was asked to spend just a few minutes talking with patients on a personal level. The person who made that request was the hospital’s manager of chaplains, Melinda Plumley, because chaplains were being kept out of COVID patients’ rooms to reduce the chance of spreading the virus. “We put together some material of easy, open-ended questions for staff to get the patient talking,” Plumley said.

The interesting thing here is that Quinteros isn’t a doctor. She isn’t a nurse or even a nurse’s aide. She’s a janitor. In a hospital, sanitizing patient rooms is a critical function, so she saw patients every day. Plumley had realized the hospital custodians were the perfect people to engage the patients with some human contact on a daily basis: they could spare a few minutes when the overworked doctors and nurses probably didn’t need any other work dumped on them.

Can that possibly work? I mean, a non-medical person doing the compassion contacts with patients to help them recover?

Colonel Denney thinks so. “It was really nice to talk about something other than my illness,” he said. “I was sick and tired of hearing about what bad shape I was in.” And, he said, “I don’t think she realized at the time what she was doing for me. She was saving my life.”

Because Denney had lost hope. Using Facetime on his phone, he had even said goodbye to his family. But Quinteros saw his fear and knew she had to engage with him, even though English isn’t her first language — she’s from Guatemala. That didn’t seem to matter. “When a patient is treated with compassion and love,” she said, “language is not a barrier.”

As they talked a little each day, they found common ground. Quinteros is married and has two children. Denny is married and has three. They’ve both traveled to other countries, and they’re both Catholic.

Denney did recover. “People don’t realize that in their brief engagements with other people, the words you say matter,” he said. “And in the situation I was in, they really matter.” After he got home he asked the hospital for Quinteros’s phone number, and then sent her a text to say thanks. When they can do it safely, he wants their two families to meet, and to take her family out to dinner so he can say thank you in person.

Working in emergency medicine myself, even just as a volunteer medic, I think the medical staff mostly does care, but they might not be very good at showing it. I know I’m not. But I realized that if a hospital custodian can do it in a language she’s not fluent in, I sure as hell can.

Not that I never do. One of the most poignant times I remember wasn’t actually a patient: it was the patient’s husband. I had to tell him his wife was dead. When I arrived, he was doing CPR on her, and I was experienced enough to know she couldn’t be revived, and that he could stop doing CPR. And as that sunk in, I told him I’d step out of the room so he could be alone with her for one last moment.

But I’ve failed in it too. Again, not with a patient! That time, I was the closest medic to a grammar school, and heard a dispatch to there for a kid who was injured on the playground. Another kid had jumped on him, and the school staff thought he might have a broken neck. I got there first, but the troops were pretty close behind me. I took the job of holding traction on the kid’s head, to keep it in line with his body as they packaged him for transport. If his neck was broken, we wanted to make sure he didn’t end up paralyzed. Sure, odds were his neck wasn’t broken, but if it was, the risks were catastrophic.

After putting the kid in the ambulance, I was about to jump into my car to leave when I spotted the other kid — the one who jumped on the boy. His mom was leading him to their car to go home, and he was crying. I looked at that for a moment, couldn’t think of anything I should say, and left. And that decision haunts me to this day, because within 10 or 15 minutes, I realized what I should have said to him.

I should have stopped mom, gotten down on my knee so I’d be at his level, look him in the eyes, and tell him I know what just happened was scary. It looks like his friend is really hurt, but he’s probably not. He just needs to go to the doctor to be checked to make sure of that, and he’s probably going to get to go home in time for dinner. He’ll probably be sore tomorrow, but he’ll be OK. OK? And then let him talk or ask any questions he had.

You know, all that would probably only take around 40 seconds. I’ll submit that’s likely the most important 40 seconds in medicine, and you better believe I’m going to spend those few seconds with every patient I interact with, now that I know about this missing element in healthcare. I hope your doctor has learned about it too.

The Show Page for this episode is thisistrue.com/podcast73, where I’ll link to the story about Quinteros and Denney, and to Dr. Trzeciak’s TEDx talk. Also there, I’d love for you to leave a comment if you’ve felt compassion from your doctor — or a medic! — in a serious health incident: I’d like to how you feel about it now that you know how important it is.

I’m Randy Cassingham … and I’ll talk at you later.

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10 Comments on “073: The Missing Element

  1. About 4 years ago, I had a strangulated hernia. It was particularly difficult because it was in my upper abdomen and the docs were afraid it may have partially involved my stomach as well. They kept me totally NPO (nothing by mouth, not even ice chips) for FIVE days, hoping it would correct itself. I was finally scheduled for surgery.

    I’ll never forget my surgeon, just as I was being put under, leaning over me and saying, “I want you to know, it’s not likely you’ll survive this surgery.” That’s the last thing I heard before the anesthesia took effect. I later found out that he also went to the waiting room and told my husband and my brother the same thing. My brother got up and towered over the surgeon and told him, “You don’t know my sister.”

    Well, as you can tell, I did survive the surgery. What made me really angry was when the nurses told me that this doctor was crowing all over the hospital about how he had saved me from certain death. I was so tempted to report him to the hospital board, but didn’t. He retired just a few months later, so I know he’s no longer treating patients that way.

    What an absolutely inhuman jerk. THAT is ego talking, not compassion. How nice to know he is no longer practicing, but how many “victims” did he have over his pathetic career?! -rc

    Reply
    • Even though “Dr. Ego” has retired, he more than likely retains some sort of licensure, and is able to return to practice. I would write a letter to the State AMA Ethics Committee about him. Randy has it right, he’s an absolute inhuman jerk. If he pulled something like that on you, who knows what else he has done to boost his ego at the expense of the well-being of a patient.

      Please, do us all a favor and report him.

      Reply
  2. You say “ Working in emergency medicine myself, even just as a volunteer medic”. I’ve been reading you for a very long time and I know your skills are at a high level & that you are constantly learning new things. I suggest that a better wording would be “Working in emergency medicine as a volunteer medic” — get “just as” out of there!

    And I’ve written before about my unfortunately large number of times I’ve been the patient. When I was really in a dire situation, I’ve said before that there is always one medic that talks to me. And that voice encourages me to hang on, one minute at a time. That voice leads me back from the black of unconsciousness, it explains what is happening, it answers my questions patiently and with a sure and steady voice. That voice — that is compassion in action. For those moments, the link between me and the voice (and its owner!) is total — the world basically doesn’t exist outside that lifeline for me.

    That is compassion — anything going on in the medic’s life might as well not exist — it is totally pushed to the side. The same is true of me. I *know* that person sees me, hears me, and understands me. That level of connectedness is extreme and can’t easily occur outside the intensity of a crisis, but I think it is worth pondering why it is so easy when you are the medic. However, even a little comment from a medical provider can form the beginnings of a compassionate link. I once had a rather aloof surgeon who saw a clever little reading light of mine. He was *fascinated* by it and wanted to handle it after I’d showed him how it worked. That really was a breakthrough — he took more than 40 seconds and we both were able to see the human side of the other rather than just stay in our assigned patient/doctor roles.

    We can quibble over “just as,” but a very experienced volunteer and a very experienced full-timer are different. Yes, I used to be full-time, but that was a long time ago. But as for your medic who talks to you while unconscious: most of us do that, because we know that even “completely unresponsive” people can often hear us, so we should communicate what we’re doing, that we’re there to help them, etc. Sometimes we forget, but it IS important, as your experiences show. That medic would LOVE IT if you reached out to tell him that. He and his colleagues need to know that it makes a difference. -rc

    Reply
  3. I’m a retired Army Nurse (LVN/LPN), and was also trained as an EMT back at the beginning. I did not start my Army career in the Medical Field, but rather, in the Infantry and Signal Corps. After 7 years of service, I made the switch, and, as a non-medic, went to the Army’s practical nursing course. Saying all that to lead up to what I saw as a conundrum: we were taught to never, ever, get emotionally “close” to our patients.

    Because I had not had that lesson instilled in me through Combat Medic training, the lesson was never really learned. And there were patients who I became emotionally close to.

    That causes other problems for the practitioner, when you become “involved” with your patients, you then have “feelings” for them, and when outcomes are not what are expected and hoped for, you again have “burn-out.”

    Contrary to what Dr. Trzeciak has found, sometimes stepping away, “taking a vacation,” is not only a viable solution to the burn-out, it becomes a necessity for the practitioner’s mental well being. It is, I believe, the reason that the Army Medical Corps insists on their personnel taking their allocated leave time during their assignments. (I was once ordered to take no less than 15 days of leave, and recommended to take the maximum allowed of 30 days. Those in charge over me could see what I could not, that “burn-out” was affecting my professional abilities.)

    I wouldn’t consider “an emotional response to another’s pain or suffering involving an authentic desire to help” (which I also described as “to connect at a human level with their patients” — for 40 seconds! — and “some human contact”) to be the same as “emotionally involved,” which wording most would use to describe a love affair (even of the “puppy” variety). As for burnout, Dr. Trzeciak’s whole point is you wouldn’t need to “get away” if you did spend that 40 seconds on a human level with each patient. But don’t take that too far: he’s not saying no one should take a vacation! He’s simply saying that the medical profession has looked at this situation the wrong way, and there is a more effective “treatment” for burnout — which also recognizes each patient’s humanity — unlike the surgeon discussed two comments back. -rc

    Reply
    • Actually what you describe is what we were taught to avoid, not the “falling in love” with our patient, just the emotional attachment with another person. How the hell we were supposed have empathy with our patients without some sort of emotional attachment? I never figured that out, and hoped that I never would. Been retired from the field due to deafness from flight operations for a little over 20 years now.

      I some way, every patient I ever treated in a long term situation, I had some sort of attachment to. Kind of hard not to when you are treating them for 8 or 12 hours for several days, or longer. Even in an ICU when vented and in medically induced paralysis. Asking them questions because you know they can hear you, even if they are unable to answer, there is a connection.

      I understand what you were taught years ago. The thing about medicine is that more research brings changes to the way things should be done for best effect. That said, it pretty much sounds like you were intuitively doing what is discussed here. -rc

      Reply
  4. I was in the hospital recently for a double bypass. It was a planned procedure, not an emergency. I was amazed at the amount of time that numerous people spent with me. From the doctors (at least four) to the nurses, to the CNAs, and the students. I was, in the beginning, having hallucinations, and have no real memory of many of the people who were helping me, but I knew, and still remember, that they were there. That helped with my recovery.

    And after I was moved to cardiac rehab, there were people around all of the time that I was awake, even late at night. They weren’t always trying to get me to to go to sleep at night, either.

    One spent a good deal of time taking my detailed medical history (and, at 65, I have a good deal of it). RNs, CNAs, physical and occupational therapists, and the room custodian, who always asked if she could get anything for me. They connected, even if it was in small, non-medically-related ways.

    Wow. “That helped with my recovery.” really says a lot, too. -rc

    Reply
  5. This can also be applied to workers in other fields. I am an instructional aide in a high school working with special needs kids. I have to be able to take the time to listen to them, to make sure that they know I care and will help them as much as I am able. Good teachers, administrators, managers, parents, good people in general will be much better at their jobs if they take those few seconds to show compassion for those around them. And that goes for everyone. Compassion can be learned and in the end, it will improve the world.

    Reply
  6. Years ago when I had a hysterectomy my surgeon held my hand as they put me to sleep. I felt comfortable and safe and not a bit anxious. When she came to me after and told me she’d been afraid that I had cancer everywhere when she got her first look at my organs, I knew I’d chosen my surgeon well. She followed that remark up by immediately telling me there was no cancer. But in that moment I knew I was in great hands and had nothing to fear. I made a quick recovery and still think of that Doctor fondly. She practiced compassion with her medicine.

    I also realize that I invite that compassion as a patient by encouraging Medical practitioners to see me as an individual by engaging them in my life with laughter or a story. I get excellent medical care because I let my caregivers know I see us as partners.

    That last thought is actually pretty profound. We as patients do have some responsibility in this exchange. We can’t just be a lump on the gurney, even though that’s a common first inclination when afraid. -rc

    Reply
  7. When I was 15 I had an angiogram to my brain (I ended up being fine). In recovery I started coughing, which caused a hematoma at my groin. I told the nurse next to me it was starting to hurt and a lot of activity started happening. A doctor came running over and before he did anything, he looked at me and said, “This is going to hurt.” He pressed down on that area with both of his hands as hard as he could to stop the bleeding. And he was right. It did hurt a lot. But I’ve always appreciated those few seconds he took to treat me like a person instead of just something that needed to be fixed.

    Yep, it’s appropriate even in a life-threatening emergency! -rc

    Reply
  8. There has been a profound improvement in “bed manner” over the years. It seems (luckily) that all the docs, dentists and nurses all do a much better job of emphasizing with patients than they did 50 years ago. I am pleased to say that I feel that with only two exceptions, all of my current caretakers, even new ones, seem to really care about me as a person, respect my opinions and fully inform me of everything I need to know about my conditions and medications.

    The two that did not have that compassion were both proctologists — they were both in the right field since they were both A-holes!

    Reply

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