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

• 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

Compassion in health

How did we get here and where are we going?

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 . . .

I really want to do a PhD developing a self‐compassion intervention for doctors That’s a beautiful thing Tony. Really. Like Martin Luther 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 Contentment Excitement Drive Connection Compassion

Urge to care

(Approach) Prosocial States

• Connection
• Empathy
• Sympathy
• Compassion

Definitions

Empathy Recognising another being’s emotional state Inferior parietal cortex (understanding others,

feeling their pain)

Compassion Witnessing suffering + wanting to alleviate suffering Dorsolateral PFC and communication with nucleus accumbens (emotion

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

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

Environmental and Institutional Factors Clinical Factors Physician Compassion Physician Factors Patient & Family Factors

Study 1 – an eye opener

• Participants: 85 medical students (34% male, 50%

Pakeha) from the University of Auckland; most in 2nd/3rd 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 DAVID: teacher, IBS following chemo for lymphoma, grateful ALAN: asthmatic smoker, well‐ dressed and pleasant Low responsibility/Negative presentation High responsibility/Negative presentation BRENDAN: pain patient, tried rehab, wants more Tramadol; angry ERIC: obese, BP, dirty, smelly, non‐ adherent; has 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 DAVID: teacher, IBS following chemo for lymphoma, grateful ALAN: asthmatic smoker, well‐ dressed and pleasant Low responsibility/Negative presentation High responsibility/Negative presentation BRENDAN: pain patient, tried rehab, wants more Tramadol; angry ERIC: obese, BP, dirty, smelly, non‐ adherent; has genital warts

• 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

Results – impact on recall and care

• 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

Observation #3

Compassion: it’s not all (or even mostly) about the doctor

The Transactional Model of 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

Environmental and Institutional Factors Clinical Factors Physician Compassion Physician Factors Patient & Family Factors

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 DAVID: teacher, IBS following chemo for lymphoma, grateful ALAN: asthmatic smoker, well‐ dressed and pleasant Low responsibility/Negative presentation High responsibility/Negative presentation BRENDAN: pain patient, tried rehab, wants more Tramadol; angry ERIC: obese, BP, dirty, smelly, non‐ adherent; has genital warts

• 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

Results – impact on recall and care

vs.

• The legislative and physical environments in which

we work also impact compassion

• Interruptions don’t help
• Obligation may help some people

Observation #4

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

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

Environmental and Institutional Factors Clinical Factors Physician Compassion Physician Factors Patient & Family Factors

Where we’re at now . . .

• The capacity for compassion in innate and shared

across species

• In medicine, compassion is more than the ‘soft’

side practice – it’s a responsibility (and privilege) that benefits patients and contributes to work QOL

• Compassion (rather than compassion fatigue)

should be the focus of scientific study

• Compassion is a systemic problem requiring

systemic solutions

• Compassion can (and should) be trained

• Compassion to self
• Compassion to others; in the clinics/ hospitals

• Having the intention- May I Be of Benefit (BOB)
• Reminders of the intention e.g. wristbands, lanyards,

auditory cues

• Train the mind to see everyone as exactly like you- with

baggage, dramas, suffering, dreams…all of us want to be happy and be free from suffering

• Compassion training
• Buddhist tradition
• Recent protocols (Stanford, Emory)

• Not just to ourselves
• But to other beings as well

The start of something beautiful . .

• NZ’s first compassion‐dedicated conference
• Globally, the 2nd ever compassion in health event
• With no advertising budget, 300 “seats” sold out 2

months before the event

• Attendees from all of NZ’s DHBs, most universities,

and Australia

• We have doctor, nurses, psychologists, and others,

specialists and generalists, students and practitioners

This says something about all of you

Today’s schedule of events

• 9:00‐945am: Dr. Fernando & Prof. Consedine
• 9:45‐1030am: Dr. Anne O’Callaghan
• 10:30‐11am: Vinayak Dev & Tony Fernando
• 11:00‐11:30am: MORNING TEA
• 1130‐12:00pm: Dr. Ingo Lambrecht & Dr. Jo Egan
• 12:00‐12:30pm: Dr. Anna Friis
• 12:30‐1:00pm: Prof. Bruce Arroll
• 1:00‐2:00pm. LUNCH
• 2:00‐3:00pm: Keynote (Dr. Robin Youngson)
• 3:00‐4:00pm: Panel Discussion
• 4:00pm: FINISH

Housekeeping

• Breaks – Please don’t eat the special food unless you

requested it

• Social Media – conference open to social media unless

presenters indicate otherwise. Use #compassioninhealthnz

• Paperless – conference is paperless
• Bathrooms – bathrooms are not paperless
• Fire Exits – Alarm will sound. Follow staff in “high vis” vests

to evacuation point on grass. Staff will check all rooms and toilets.