Survey: Compassionate care could mean life or death

The Schwartz Center surveyed 800 patients, 500 physicians

A majority of patients and physicians polled in a national survey believe not only that health care delivered with compassion can make a difference in how well a patient recovers from illness — it can also make a difference in whether a patient lives or dies.

The survey, commissioned by The Schwartz Center for Compassionate Healthcare at Massachusetts General in Boston, was a national poll of 800 patients and 500 physicians about "the state of compassionate health care in the United States," according to Beth A. Lown, MD, medical director of the center. The center's programming focuses on facilitating and educating clinicians on the compassionate delivery of care, primarily in the hospital setting, but also in some outpatient settings, nursing homes, and managed care organizations, according to The Schwartz Center's Executive Director Julie Rosen.

The survey, conducted from Sept. 23 to Oct. 29, 2010, asked a series of questions about the importance of compassionate health care to both groups, Lown explains. The patients were those who had been hospitalized for at least three days within the past 18 months. The physicians were those who spend at least some of their time taking care of hospitalized patients.

"I think what was so striking is that moving from . . . treatment is important in recovery, the majority of both doctors and patients said it's important; and it makes a difference in whether patients live or die — that's astounding," she tells Medical Ethics Advisor.

And while, as an internal medicine physician, Lown says she thinks the profession believes in the importance of compassionate health care, she "still was surprised that they said it made a difference in life or death."

The national survey excluded uncomplicated pregnancies, "because we wanted to get at the people who had really had something significant wrong in order to be hospitalized in those circumstances."

According to the center, the poll found that patients and doctors generally agree about the most important elements of compassionate care, which were defined in the poll as:

  • showing respect for patients, their families, and those important to them;
  • treating patients as people, not a disease;
  • conveying information in a way that is understandable;
  • listening attentively to patients;
  • gaining the patient's trust.

Despite agreeing on the potential impact on the patient of compassionate care, there were specific elements on which physicians and patients did not necessarily agree. For example, 75% of patients rated the objective of apologizing to a patient when a physician has made a mistake as a 10 on a 10-point scale of importance. But only 54% of physicians rated this as a 10.

Likewise, 78% of patients rated communicating test results in a timely and sensitive manner as a 10, compared to 61% of physicians. Also, 63% of patients rated comfortably discussing sensitive, emotional, or psychological issues as 10, compared to 50% of physicians.

The ideal of care vs. reality

While both patients and physicians indicated that compassionate care is important, how that ideal manifests in the hustle and bustle of today's hospital setting seemed different from the type of care patients indicated they actually received during their most recent hospitalization.

For example, 83% of patients polled indicated they expected that physicians would express sensitivity, caring, and compassion, but fewer, or 67%, indicated that physicians actually demonstrated those behaviors during their hospital stay. Also, 91% of patients said they would expect that physicians would listen attentively, compared to 67% who said this is what they actually experienced in their most recent hospital stay.

As to why the gaps between the ideal and what actually occurs in the hospital care delivered may seem at odds, Lown says, "That is a bit of: Why is our health care system not able to provide as much compassionate care as patients would like to see happen? . . . So, what is it that makes the real different from the ideal? I think it's just incredibly complicated, and I don't have data from the poll to support this, but I can tell you my opinion; and I don't think it's too far from what others might say."

For starters, with the institution of DRGs, there have been "shorter and shorter lengths of stays in this country," she explains.

"That means there's less and less time for a team to get to know a given individual in a hospital," she says. "When I was starting, it wouldn't be unusual to have a patient in the hospital for a week or more. That's unheard of now, and that actually . . . impairs your ability to really get to know the patient and his or her concerns. So, it's a very rapid throughput in the hospital these days. That's one issue."

"The second issue is that technology, over time, has superseded presence and touch," Lown says. "So, rather than really having the system encourage people to go and sit at the bedside and actually elicit a robust history — and by that I mean one that has both the clinical clues that you need to really understand and make a diagnosis and fashion therapy — but also the psychosocial, the emotional, the psychological clues that help you understand the context of the patient. The systems don't make it easy to do that at all."

And while reimbursement doesn't really exist for time spent conversing with the patient, Lown maintains that it doesn't really take "a tremendous amount of time."

"It takes focused presence; it takes attention; it takes mindful listening; it takes empathic resonance; but I think people fear that [this type of conversation] will open a Pandora's box that they don't know how to manage or they won't have time to manage," she says.

The impact of hospitalists

Another factor in shaping the reality of care vs. the kind of care patients say they want is the impact of the hospitalist movement over the past 10 years, Lown says.

There are both advantages and disadvantages to the rise of hospitalists providing care in the hospital setting, but it has meant that primary care doctors are "less and less present in the patients' hospital experience; some people think that's good, and some people . . . grieve that loss," she notes.

The hospital environment of today has "become an increasingly fast-paced, technical method of taking care of acutely ill patients that doesn't necessarily prioritize or honor the patient's experiences in the way they wish they could have," Lowns says.

Sources

  • Beth A. Lown, MD, Medical Director, The Schwartz Center for Compassionate Healthcare at Massachusetts General, Boston. E-mail: balown@partners.org.
  • Julie A. Rosen, Executive Director, The Schwartz Center for Compassionate Healthcare at Massachusetts General, Boston. E-mail: jarosen@partners.org.