My friend, emergency medicine colleague and educator Barbara Tatham, MD, died of metastatic sarcoma at the age of 32 in October 2019. During her last year of life, in between rounds of chemotherapy and radiation, she gave lectures on compassionate care that were inspired by her journey as a patient. This column is part of my vision to continue her voice as a champion of compassionate care into the future.

Emergency medicine demands we regularly face patients with extreme emotional lability, pain, and suffering. We pride ourselves in adapting to repeated traumatic events, apparently unscathed. We do this to protect ourselves, partly because we all have an innate ability to depersonalize after these repeated traumatic events, as humans do in wars and famines. We also do this so we can expertly execute a pediatric airway or thoracotomy despite the chaos of the emergency department.

This adaptive depersonalization poses a significant problem to quality patient care—and specifically to compassionate care. We have a responsibility to provide compassionate care, as stated in the American Medical Association Code of Ethics: “A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.”¹ Compassion is an emotional response to another’s pain or suffering that involves a desire to help. Compassion is not simply “feeling bad” for a patient. It requires a desire to help and act accordingly. Compassion, like any behavior, can be learned—contrary to the popular belief that compassion is an innate quality that one either possesses or does not.

It is no surprise that emergency physicians are not experts in compassionate care because few training programs include it in their curricula. Our ability to provide compassionate care erodes through the course of our training and, as a community, with each passing year.^2,3 The person (as opposed to the patient) in the stretcher in front of us is more than a particular diagnosis or a disposition dilemma. They are often frightened, anxious, concerned, or emotionally numb. Addressing these emotions is paramount. The good news is that it is easy to provide compassionate care in an efficient manner. There is evidence to suggest that when physicians spend only 40 seconds saying compassionate statements, patient anxiety is significantly reduced.⁴ Although it seems counterintuitive, when you invest time in other people, you feel that you have more time, that you are not in as much of a hurry. Effective communication that incorporates compassionate statements results in shorter, more efficient visits.⁵

Physician Compassion Associated with Improved Patient Outcomes

Patients with life-threatening emergencies benefit from physician compassion, as suggested in one study that showed fewer post-traumatic stress disorder symptoms among patients treated with compassion.⁶ A study of surgical patients demonstrated that compassion delivered by nurses or doctors just prior to surgery resulted in patients anxiety in patients, easier sedation, less need for postoperation opioids, and shorter hospital stays.⁷ A review of physician-patient communication, including compassionate care, and health outcomes in 21 studies demonstrated an association between compassionate care and symptom resolution, function, physiological measures such as glucose control, pain control, and emotional health.⁸ The more compassionate behavior is used by physicians, the more likely patients are to trust their advice, comply with treatment recommendations, take medications, and follow discharge instructions.⁹

Physician Compassion Associated with Decreased Medical Errors, Physician Burnout, and Litigation

ACEP staff is thinking constantly of our members and the health care heroes in emergency departments worldwide. We are so proud of your brave and selfless work to combat this virus. Communications Manager Jordan Grantham captured our sentiment and support with this artwork. Stay safe and know that ACEP is here for you—today and every day.
Jordan Grantham

While depersonalization is a coping mechanism for emergency physicians, it is a sign of burnout, along with emotional exhaustion. Physicians who score in the highest tier of depersonalization and emotional exhaustion commit the most medical errors, and those with high empathy scores have more job satisfaction and less burnout.^10,11 Compassionate care makes us feel good as it gives us a “helper’s high,” the feeling of reward that comes from helping others.¹² Complaints and litigation may be curbed by improved physician compassion.¹³ This is eloquently demonstrated in an ED waiting room study that randomized patients to watch either a simulated physician-patient discharge conversation that included two empathic statements (the physician recognizes that the patient is concerned about their symptoms and that the patient knows their typical state of health better than a physician seeing them for the first time so they did the right thing by seeking evaluation) or one that did not. The group who watched the video that included the empathic statements had significantly fewer thoughts of litigation and complaints about the physician.¹⁴

Physician Compassion Associated with Lower Health Care Costs, Improved Resource Utilization

Patients who receive compassionate care not only tend to recover faster from their illness but are more likely to have fewer visits, tests, and referrals.¹⁵ Furthermore, compassionate care is associated with fewer unnecessary admissions and lower total health care costs.¹⁶ A randomized trial of compassionate care for homeless patients in an urban emergency department found that compassionate care decreased repeat visits to the emergency department.¹⁷

Here are some tips to help improve your compassion:

• Before entering a patient room for a new encounter, leave behind thoughts of your previous patient, regroup, and quiet your mind so you can be present.
• Thank the patient for waiting, make sure they are comfortable, and begin the encounter with an empathetic statement.
• Sit down, lean in, and smile; make the patient feel like you care they are there.
• Let the patient tell their story. Patients only need, on average, 29 seconds to fully describe their main concern yet are typically interrupted after 11 seconds.¹⁸
• Look at the patient and listen to all their concerns.
• Empower them with relevant education and involvement in their treatment plan.
• Set expectations and explain timelines.
• Ask if they have any questions.
• End with a compassionate statement:
  • “I am here with you.” 
  • “We will get through this together.”

If you asked me if I was compassionate with my patients in the emergency department a year ago, I would have certainly judged myself harshly and said no. After studying compassionate care, compassion is with me almost always. Granted, I still find it hard to incorporate compassionate care when I’m really stressed and exhausted, and there are certainly ED patients who make it hard to be compassionate. But in those moments when I’m stripped of my compassion, I can feel it. I feel that something huge is missing. What do I do? I pause, I breathe, I pivot, and I pull out a couple of those easy-to-remember compassionate statements and just say them. Suddenly, I feel better; I’m quite sure my patient does, too.

Compassionate care is a skill that can be cultivated and grown by each of us. I contend that compassion needs to be integrated into our training and CME. Learning compassionate care allows us to develop our own resilience as emergency physicians in our demanding environment. Compassion is not simply part of our nature, and we shouldn’t take it for granted. When we act out of compassion for a fellow human being, it has profound meaning. It is a real privilege that we all have—to take care of patients in the emergency department and use our knowledge and skills not just to fix their immediate problem but to heal them. You can always find compassion in the chaos of the emergency department. Find your compassion. Cultivate it. Use it. 

Try compassionate care for yourselves, your patients, and your colleagues, and keep in mind some of the overall benefits outlined in this article. As you feel more comfortable, model it for others and help change the culture. If you can, start a discussion, make compassionate care known, and allow it to grow. You and your patients will benefit immeasurably.

References

1. AMA Principles of Medical Ethics. American Medical Association website. Accessed March 28, 2020.
2. Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84(9):1182-1191.
3. Neumann M, Edelhäuser F, Tauschel D, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011;86(8):996-1009.
4. Fogarty LA, Curbow BA, Wingard JR, et al. Can 40 seconds of compassion reduce patient anxiety? J Clin Oncol. 1999;17(1):371-379.
5. Brown RF, Butow PN, Dunn SM , et al. Promoting patient participation and shortening cancer consultations: a randomised trial. Br J Cancer. 2001;85(9):1273-1279.
6. Moss J, Roberts MB, Shea L, et al. Healthcare provider compassion is associated with lower PTSD symptoms among patients with life-threatening medical emergencies: a prospective cohort study. Intensive Care Med. 2019;45(6):815-822.
7. Pereira L, Figueiredo-Braga M, Carvalho IP. Preoperative anxiety in ambulatory surgery: the impact of an empathic patient-centered approach on psychological and clinical outcomes. Patient Educ Couns. 2016;99(5):733-738.
8. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152(9):1423-1433.
9. Roter DL, Hall JA, Merisca R, et al. Effectiveness of interventions to improve patient compliance: a meta-analysis. Med Care. 1998;36(8):1138-1161.
10. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
11. Jeffrey D. Empathy, sympathy and compassion in healthcare: Is there a problem? Is there a difference? Does it matter? J R Soc Med. 2016;109(12):446-452.
12. Raposa EB, Laws HB, Ansell EB. Prosocial behavior mitigates the negative effects of stress in everyday life. Clin Psychol Sci. 2016;4(4):691-698.
13. Smith D, Kellar J, Walters EL, et al. Does emergency physician empathy reduce thoughts of litigation? A randomized trial. Emerg Med J. 2016;33(8):548-552.
14. College complaints on the rise: Better communication can help. 2018. Canadian Medical Protective Association website. Accessed March 28, 2020.
15. Orzol S, Keith R, Hossain M, et al. The impact of a health information technology-focused patient-centered medical neighborhood program among Medicare beneficiaries in primary care practices: the effect on patient outcomes and spending. Med Care. 2018;56(4):299-307.
16. Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med. 2011;24(3):229-239.
17. Redelmeier DA, Molin JP, Tibshirani RJ. A randomised trial of compassionate care for the homeless in an emergency department. Lancet. 1995;345(8958):1131-1134.
18. Marvel MK, Epstein RM, Flowers K, et al. Soliciting the patient’s agenda: have we improved? JAMA. 1999;281(3):283-287.