Compassion in health How did we get here and where are we going? - PowerPoint PPT Presentation

Compassion in health How did we get here and where are we going? Prof. Nathan S. Consedine & Dr. Tony Fernando Department of Psychological Medicine, University of Auckland Opening Session at the Compassion in Healthcare NZ 2019 Conference, Auckland, March, 2019

Acknowledgements  Faculty: Dr. Lisa Reynolds, Profs. Bruce Arroll and Andrew Hill  Students: James Cameron, Tobias Barker, Sigourney Taylor, Harry Yoon, Kat Skinner, Lauren Barker, Amy Clucas, Jess Polo, Jane Cha, Vinayak Dev, Tony Sriamporn  Funding: UoA Summer Studentship Program  Participation: 1500+ doctors, 800+ nurses, 600+ med students

Like Hot Chocolate said: it started with a . . . That’s a beautiful I really want to do a PhD thing Tony. Really. developing a self ‐ compassion Like Martin Luther intervention for doctors King and JFK beautiful . . . ..

Overview & Introduction  Where we came from . . .  Where we ended up . . . .  Compassion as a value: innate and pleasurable  Compassion as a science: some observations  Observation 1: compassion matters  Observation 2: compassion fatigue is unhelpful  Observation 3: it’s not all about the doctor  Observation 4: compassion in medicine isn’t special  Practical implications  Where we’re going: today, tomorrow, and the future

Calm Excitement Connection Contentment Drive Compassion

Urge to care

• Connection (Approach) • Empathy Prosocial • Sympathy States • Compassion

Definitions Empathy Compassion Recognising another Witnessing suffering + being’s emotional state wanting to alleviate suffering Dorsolateral PFC and Inferior parietal communication with cortex (understanding others, nucleus accumbens (emotion feeling their pain) regulation and positive emotions)

Why bother with compassion? • Because we benefit • Decrease burnout, compassion fatigue? • Compassion Satisfaction

Brain (and body) is wired to feel VERY good when we are connected/ compassionate

For our patients and their families • Better outcomes mentally and physically

 When disconnected, rejected, uncared for-  worst human experience

Compassion not as simple as turning on a “switch” Compassion is conditional Family/ friends likeability/ similarity external environment, bystander effect stress/ pressure We are not static emotionally!

Observation #1  Compassion – a response to the suffering of others – is central to medical practice  Compassion is:  Central to patient values and satisfaction  Central to physician motivation and work ‐ related enjoyment  Legislatively required in most countries  Predicts better patient outcomes Compassion: the (real) “Big C” in healthcare

Observation #2 • Compassion fatigue is the dominant framework in the study of physician compassion (20 ‐ 70% prevalence) • Based in the “knowing” that caring for others is tiring Fig 1: SCOPUS data for number of studies on compassion fatigue

How do I hate thee . . .  Let me count the ways . . .  Compassion fatigue is a deeply flawed concept and risks becoming the lens through which we thing about compassion in health Compassion fatigue is real, but not a (real) useful way to think about compassion in healthcare Elizabeth Barrett Browning

Observation #3 Fernando, A. T., Arroll, B., & Consedine, N. S. (2016). It’s not all about the doctor: enhancing compassion in general practice. British Journal of General Practice, 66 (648), 340 ‐ 341.

Empirical validation Fernando, A. T. & Consedine, N. S. (2014b). Beyond compassion fatigue: Development and preliminary validation of the Barriers to Physician Compassion Questionnaire. Postgraduate Medical Journal, 90, 388 ‐ 395 .

The Transactional Model of Physician Compassion Environmental and Institutional Factors Patient & Family Physician Factors Clinical Factors Factors Physician Compassion Fernando, A. T., & Consedine, N. S. (2014). Beyond compassion fatigue: a transactional model of physician compassion. Journal of Pain and Symptom Management. DOI: 10.1016/j.jpainsymman.2013.09.014

Study 1 – an eye opener • Participants : 85 medical students (34% male, 50% Pakeha) from the University of Auckland; most in 2 nd /3 rd year of training • Design : Randomized participants to self ‐ compassion, self ‐ criticism, or control conditions before reading and rating patient vignettes

Patient vignettes • Gender matched vignettes describe high/low responsibility and positive/negative patients Low responsibility/Positive presentation High responsibility/Positive presentation ALAN: asthmatic DAVID: teacher, IBS smoker, well ‐ following chemo for dressed and lymphoma, grateful pleasant Low responsibility/Negative presentation High responsibility/Negative presentation BRENDAN: pain ERIC: obese, BP, patient, tried dirty, smelly, non ‐ rehab, wants more adherent; has Tramadol; angry genital warts

Results – patient factors Fig 2: Patient liking, desire to help, care, and closeness as a function of patient presentation and responsibility

Results – physician ‐ patient effects Fig 3: Patient liking, desire to help, care, and closeness as a function of patient presentation and trait physician empathy

Study 2 – getting oriented • Participants : 88 medical students (58% male, aged 18 ‐ 36 yrs) from the University of Auckland from MBChB years 3 ‐ 6 • Design : Randomized to anxiety v. control and person vs. clinical focus conditions before reading/rating vignettes. • Analysis: Tested effects on care, memory, and behaviour

Patient vignettes • Gender matched vignettes describe high/low responsibility and positive/negative patients Low responsibility/Positive presentation High responsibility/Positive presentation ALAN: asthmatic DAVID: teacher, IBS smoker, well ‐ following chemo for dressed and lymphoma, grateful pleasant Low responsibility/Negative presentation High responsibility/Negative presentation BRENDAN: pain ERIC: obese, BP, patient, tried dirty, smelly, non ‐ rehab, wants more adherent; has Tramadol; angry genital warts

Results – impact on recall and care • Anxiety did not reduce compassion but it did: – Reduce the amount of information recalled – Increase willingness to wait • AND . . . being person (versus clinically) focused: – Increased liking, desire to help, and care – Increased recall of person ‐ relevant information – Increased willingness to wait Orienting to the person (rather than their symptoms) increases compassion

Observation #3 • The best predictors of compassion were not in the physician – they were in the patient • Less compassion for negative or blameworthy patients • Negativity “trumps” responsibility • Physician factors only matter with negative patients Compassion: it’s not all (or even mostly) about the doctor

The Transactional Model of Physician Compassion Environmental and Institutional Factors Patient & Family Physician Factors Clinical Factors Factors Physician Compassion Fernando, A. T., & Consedine, N. S. (2014). Beyond compassion fatigue: a transactional model of physician compassion. Journal of Pain and Symptom Management. DOI: 10.1016/j.jpainsymman.2013.09.014

Study 3 – the work environment • Rationale: Compassion (fails to) happen in contexts. Interruptions, noise, distractions may interfere with compassion • Design: We mimicked practice by randomising participants to be interrupted (or not) while they were reading vignettes • Analysis: Tested for effects of interruption on care and memory for patient data

Patient vignettes (per Study 1) • Gender matched vignettes tested to high/low responsibility and positive/negative presentation Low responsibility/Positive presentation High responsibility/Positive presentation ALAN: asthmatic DAVID: teacher, IBS smoker, well ‐ following chemo for dressed and lymphoma, grateful pleasant Low responsibility/Negative presentation High responsibility/Negative presentation BRENDAN: pain ERIC: obese, BP, patient, tried dirty, smelly, non ‐ rehab, wants more adherent; has Tramadol; angry genital warts

Results – impact on recall and care • Interruptions led to lower recall and lower care(ish) • As in Studies 1 and 2, care, liking, and desire to help were lower for negatively or high responsibility patients • The negative effect of patient factors on care ratings was exacerbated by interruptions vs.

Observation #4 • The legislative and physical environments in which we work also impact compassion • Interruptions don’t help • Obligation may help some people Compassion: it happens (and doesn’t happen) in particular places

Observation #5 • Compassion in medicine (or health) relies on the same basic (evolved) systems that govern compassion in other contexts • But it differs in: – Professionally expected/legislatively required – Repeated versus sporadic – Differing care to recipient ratios – Financially compensated Medical compassion is (and isn’t) special

The Transactional Model of Physician Compassion Environmental and Institutional Factors Patient & Family Physician Factors Clinical Factors Factors Physician Compassion Fernando, A. T., & Consedine, N. S. (2014). Beyond compassion fatigue: a transactional model of physician compassion. Journal of Pain and Symptom Management. DOI: 10.1016/j.jpainsymman.2013.09.014