Compassion in the emergency department

Humanity

CJEM 2001;2(3):208-209

The biggest disease today is not leprosy or tuberculosis, but rather the feeling of being unwanted and uncared for.

Have you ever bristled when a colleague (consultant) was abrupt or arrogant to a patient? Or recoiled from hearing disparaging words? Have you been dismayed by the unfeeling robotic way doctors gather information from patients, without so much as eye contact? We know intuitively that such behaviour is not becoming of a good physician, but does it matter? Does compassion influence patient outcomes? Or are technical competence and diagnostic skill the only requirements? In fact, recent scientific evidence shows that compassion makes a difference.

At one Toronto hospital a cohort of homeless patients was tracked over 5 years. . . . One group received usual care, while the other received "compassion care" . . . [in the latter group] monthly visits dropped to 43%­65% of baseline level.

In his book, Reinventing Medicine, Dr. Larry Dossey discusses the 3 eras of modern medicine.¹ In Era 1, during the late 19th century, medicine began with physical diagnosis, drugs and surgery. In Era 2, during the 1950s, physicians acknowledged the intricate connection of mind and body. Now, in Era 3, emphasis is shifting to non-local medicine. Thanks to research from institutions like Princeton and Harvard, we are recognizing the unity of nature, whereby compassion, interpersonal warmth, and even prayer, can influence critical molecular and cellular processes.

Present day icons, such as Dr. Deepak Chopra, have pontificated that human physiology can be altered by metaphysical means, outside of the placebo effect.² As outlandish as this sounds, given the limited parameters of our logic, eminent scientists around the world have produced data showing that compassionate care and positive thoughts can enhance survival and recovery. Some have suggested that non-local medicine is the explanation for unexpected cancer remissions and miraculous recoveries from devastating illness.¹

For emergency physicians, 2 studies are particularly relevant. In 1995, Malarkey and coworkers demonstrated that abrupt or unsettling medical encounters tended to augment serum cortisol levels for 2 days or more, while positive or reassuring encounters tended to normalize levels.³ In 1993, Armstrong and colleagues⁴ found that high cortisol levels predicted early relapse in patients being treated for peptic ulcer disease (odds ratio = 1.38).

Homeless people rely on emergency departments (EDs) for much of their primary care, yet many are met with indifference or disdain by ED staff. This dynamic may have untoward consequences. For example, at one Toronto hospital a cohort of homeless patients was tracked over 5 years. At baseline, they averaged 7 ED visits per year, and one-third of visits were followed by a next-day re-visit. The patients were then randomized into 2 groups. One group received usual care, while the other received "compassion care," where volunteers took a special interest and addressed immediate needs (e.g., personal comfort, food). One might predict that "compassion care" would encourage return visits, but the opposite happened: monthly visits dropped to 43%­65% of baseline level. For unclear reasons -- perhaps greater trust, reduced anxiety, or improved compliance -- these patients did better and were more satisfied with their care.⁵ Other studies have shown similar benefits in children and the elderly.^6,7

So, if compassionate care is important, how do we restore it to emergency medicine? Perhaps we can start by enhancing our own empathy skills. Empathy is the ability to identify with a person and understand his or her plight or feelings.⁸ Empathy helps overcome physician narcissism and aloofness in this technological age.

When medical students study the dead body and the living cell, they learn that patients are passive and cells are alive.⁹ In medical school, "science" is emphasized and humanity devalued. The art of listening, fundamental to empathy, diminishes. Yes, we hear details of the history, but are we listening to the patient's mind and spirit? Many students who begin with empathy and high ideals lose these qualities when they are faced by an emphasis on knowledge rather than interpersonal skills, and by a lack of empathy on the part of their teachers.¹⁰

We have a duty not only to our patients, but as mentors to ED physician wannabes, to hone this skill and cultivate our empathetic side. Physicians are more than the sum of pills and procedures. We need compassion and empathy to carry out our important role. Compassionate care is more than just good ethical behaviour. It is good medicine.

References

1. Dossey L. Reinventing medicine. San Francisco: Harper; 1999. p. 271.
2. Chopra D. Quantum healing. New York: Bantam Books; 1990. p. 278.
3. Malarkey WB, Pearl DK, Demer LM, Kiecolt-Glaser JK, Glasen R. Influence of academic stress and season on 24-hour mean concentrations of ACTH, cortisol and beta-endorphin.
   Psychoneuroendocrinology 1995;20:499-508.
4. Armstrong D, Arnold R, Classen M, Fischer M, Goebell H, Blum AL. Prospective multicentre study of risk factors associated with delaying healing of recurrent duodenal ulcers.
   Gut 1993;43:1319-26.
5. Rendemeier DA, Molin JP, Tibshirani RJ. A randomized trial of compassionate care for the homeless in an emergency department.
   Lancet 1995;345:1131-4.
6. Alpert JJ, Robertson LS, Kosa J, Heagarty MC, Haggerty RJ. Delivery of health care for children: report of an experiment.
   Paediatrics 1976;57:917-30.
7. Wasson JM, Sauvigne AE, Mogidniki RP. Continuity of outpatient medical care in elderly.
   JAMA 1984;252:2413-7.
8. Giarnakos D. Empathy revisited.
   Arch Intern Med 1996;156:135-6.
9. Spiro H. What is empathy and can it be taught?
   Ann Intern Med 1992;116:843-6.
10. Taylor MB. Compassion: its neglect and importance.
    Br J Gen Pract 1997;47:521-3.