Sometimes while reading a book, you can be in such agreement with the concept and so frustrated by the experience of reading.  It’s hard reading.  The research support is sometimes weak, but it’s so important, it’s worth looking past these limitations.  Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference seeks to explain how being compassionate isn’t just the morally better approach but leads to better financial outcomes as well.

The Research

I soundly criticized The Burnout Challenge for addressing research with a waving of hands that there was “ample” evidence.  There’s a reason.  I’m in the habit of looking at the underlying research to ensure that it’s quality research – and that it says what the author purports it to say.  I want to find instances like Charles Duhigg’s book, The Power of Habit, where the research doesn’t say exactly what he wants it to say.  (Daniel Pink’s Drive is in a similar category.)

That’s why I was concerned when I routinely saw the research being referred to.  The studies I sampled all had fewer than 25 people in them.  That’s so small that you really can’t reach any sound conclusions.  Those types of studies are really designed to identify a reason to do a larger study.  They’re great for what they are – but they’re not compelling evidence, just an indication that a larger study is warranted.  (Which was their conclusion.)

The Writing

Before I start with the long list of good things about the book, I’ve got to share one more challenge.  The writing is repetitive.  It’s hard to read simply because the authors are saying the same thing over and over.  The book could probably be a booklet if it weren’t for the repetition.  The good news is that it’s not as hard of a read as Servant Leadership – which is also a good book.

Be prepared to focus when you’re reading, so you can extract the value.

Compassion

Before we can get into the economic impact of compassion, we’ve got to get clear about what it is.  Simply, empathy is “I understand this about you.”  (See Sympathy, Empathy, Compassion, and Altruism and Against Empathy for more.)  Compassion extends this to say that “I understand your suffering, and I want to do something about it.”  (See Emotional Awareness for more on compassion.)

Understanding what compassion is, we also need to understand how it came to be that we are – generally – compassionate creatures.  Adam Grant in Give and Take explains that givers are at both the top and bottom of the performance curve.  Sometimes givers end up on top, and sometimes they end up on the bottom.  To understand how this can happen, we start with Richard Dawkins’ The Selfish Gene, which basically says that our genes do the things that allow them to replicate.  That makes sense.  Those that don’t replicate don’t get passed on.  However, the “how” they are most effective at replicating is more complicated than it appears.

It’s more of a discussion than is appropriate here, but Robert Axelrod uses computer simulations to understand the best strategies in The Evolution of Cooperation.  Does Altruism Exist? and SuperCooperators more fully expose the mechanisms that allow cooperators to come out ahead and how they protect themselves from takers who threaten to destroy them.

The language shifts from compassion to “give and take” or “cooperation,” but fundamentally the concepts are the same.  Are we better off caring for others?  The answer across evolution and even Jonathan Haidt’s work in The Righteous Mind seems to say yes.

Mechanical Precision

Medicine, in its search for efficiency, has turned to shorter and more tactical appointments.  Doctors have, unfortunately, responded by interrupting their patients more quickly as they describe their primary complaint and their environment.  In short, they’ve made the decision that there’s not enough time to listen to the patient.  In the process, they’re alienating the patient, making poor diagnoses, and driving higher levels of healthcare access than are needed.

How quickly are they interrupting?  It varies over time – but within a minute.  In the standard 15-minute appointment, it’s a non-zero percentage – but if you believe Einstein, understanding the problem is the key thing in any problem-solving activity.

More challenging is that doctors are rarely listening to the broader context of the person, problem, or environment.  As a result, they’re often prescribing things that just don’t work.  They may not be solving the real problem – but more frequently, they’re proposing things that patients just won’t do.  It will get labeled as patient non-compliance, and that’s not their fault – or is it?

Patient Non-Compliance

It’s a big problem in healthcare.  The failure to follow the prescribed protocol for medication, exercise, or diet leads to a substantial amount of medical costs.  (Change or Die informs us that five behaviors drive 80% of the healthcare system cost.)  When the doctor prescribes a medication that is too expensive for the patient’s means, isn’t covered by insurance, or there’s no way to get it at a price the patient can afford to pay, the patient won’t take the medication.  It seems obvious, but if you’re not listening to the patient – and their entire situation – it isn’t.

Emotional Factors

When a doctor asks you how you’re feeling, you expect that they’re asking about your perception of pain – not your emotional state.  Despite better standardized screening, most of the time, doctors don’t ask about your psychological or emotional state.  They don’t believe that it’s any of their concern – or business.  It’s like the brain is the passenger in the vehicle called the body and that the passenger doesn’t have any control.

We know that the way we think, what we perceive, and our emotional state has a huge impact on physical health, but it remains undiscussable in most visits.  Those are the sorts of things that behavioral health is supposed to handle, not the doctor – or so they think.  Loneliness explains that being lonely can have a more significant health impact than smoking or abusing alcohol combined.  It matters, and it’s something doctors should be doing something about – but aren’t.

The Curriculum

Though, today, the need for compassion is seen as more essential than any other time in our history, it’s still common to hear of programs that explicitly or implicitly teach that nurses listen to patients, not doctors.  Doctors are the expert – and the patient would do well to listen to them.  Carl Rogers, a prominent psychologist, would likely disagree.  He believed that the client (or patient) is the expert on their life.  The practitioner knows their field, but they don’t know the person’s details.  This recognition that the client/patient is the expert is at the heart of Motivational Interviewing – which is effective at resolving substance use disorder (SUD) in ways that neither medicine or traditional counseling can be.

Sometimes the message sent in the curriculum is that the science of medicine – knowing the right values, drugs, and systems – is the only part of medicine that matters.  However, without patients, none of that information will matter.  Another explicit or implicit message may be that you must remain distant and detached from your patients.  However, compassion requires that you understand their pain – and want to resolve it.  You can’t do that if you’re detached.  You won’t have any patients if you don’t demonstrate the “art” of medicine through compassion.

Burnout

Unfortunately, the authors head off into places where they don’t fully understand the space, including burnout.  They insist that personal connections protect people from burnout – despite limited evidence that relationships alone are sufficient.  In fact, it’s special relationships that seem to have protective effects, not just any relationship.  While depersonalization of patients will reduce compassion, it’s not a one-to-one relationship.  It’s the depersonalization that matters – not the degree to which they’re burned out.  Sure, it has a negative impact on care, but it’s tangential to the compassion problem.

Part of the confusion is equating burnout with compassion fatigue; though they’re similar, they are still distinct.  (See Is It Compassion Fatigue or Burnout?)

PTSD

Similarly, the authors speak as if they are authorities on PTSD, but they fail to understand it at more than a cursory level – and don’t understand the factors that drive it.  (See Trauma and Recovery, Posttraumatic Growth, and Trauma and Memory for more about how trauma functions.)

Concealing Major Errors

The final error that is worthy of mention is that they equate anonymous surveys as being able to generate honest responses.  First, the providers need to believe they’re anonymous – and they’re often skeptical.  Second, they must overall feel psychologically safe enough to admit a problem even anonymously.  (See The Fearless Organization.)  Finally, they must believe that there was a “major error.”  What constitutes a major error anyway?  Maybe everything short of a mortality event isn’t major.  Even if they define major error more conservatively, they may not believe it’s their fault.  (See Mistakes Were Made (But Not by Me) and How We Know What Isn’t So.)

In the end, the authors made some major errors – and some valid points – in Compassionomics.