Introduction
Anthony Mazzarelli here. But call me Mazz.
In 2013, I became the chief medical officer (CMO) of Cooper University Health Care—an academic health care system that includes an affiliated medical school, flagship hospital, a Level 1 trauma center, and one hundred other sites in southern New Jersey, now with $1.6 billion in annual revenue and around 8,500 employees. I was thirty-eight years old, which seems impossibly young in hindsight. Needless to say, I’d never been a CMO before, and Cooper had never had a practicing emergency medicine physician in the position before either. My qualifications were my experience as a doctor at the hospital, my law degree, and, I think, my ability to get along with others. I knew going in that the CEO and the board had taken a chance on me, and I dearly hoped they’d put their faith in the right person.
Shortly thereafter, in 2014, the CEO told me that she’d hired a top consulting company that deals with employee and physician engagement and patient satisfaction. “They’re the best, and they’re going to help us,” she said.
I was all for it. I’m not going to refuse help when it’s offered. So I met with the consultants and they gave me a list of things that we had to get our then five hundred physicians to do to make improvements. I remember jotting down “say thank you,” “introduce yourself,” “listen more,” “don’t interrupt,” and “nod a lot.” Boiled down, the message was that our faculty needed to show more compassion and to connect with patients and one another.
I listened and nodded (and didn’t interrupt once) through the presentation, but the whole time, I was thinking, “I’m never going to be able to get the physicians to do this mushy stuff.” Apologies to doctors, but we’re not always known for our soft skills or at least not known for changing our ways with those niceties. (I can practically hear my medical school professors who believed customer service wasn’t their responsibility, saying, “That’s what nurses and social workers are for.”) Our faculty were academic types, doctors who’d been doing it their way for thirty-plus years and, as the faculty of our medical school, have been teaching others that same way. If I gave them the new mandate, many, if not most of them, would roll their eyes and say, “I’m already compassionate” or “What a waste of time and energy.” They’d brush away the advice of this consulting group like lint off their shoulders.
Compassion: recognizing the suffering of others and then taking action to help.
When I started medical school, compassion wasn’t explicitly part of our curriculum. It wasn’t the title of any lecture. It wasn’t the answer on any test. As a student and as a doctor, I learned about compassion in the halls and patient rooms of our hospital. I’ve seen its power but felt its effects most deeply when I was on the other side of the equation.
In 2013, my pregnant wife, Joanne, and I rushed to the obstetrics (OB) department at Cooper in a panic. Joanne, a cardiologist, and I had reason to worry. Even though she was full term, days away from her due date, she hadn’t felt the baby move for hours. The nurse tried to find the heartbeat and couldn’t, but she never let on that she was worried. She remained calm and spoke to us in a soothing voice.
The OB physician came in rolling an ultrasound machine with her and introduced herself with the same calming, reassuring tone, somewhere between “I know this might be really bad” and “Everything’s going to be okay.” It seemed to strike the right balance, which was: “You’re in the right place, and you’re going to get the right care for right now.”
But it wasn’t going to be okay. Using the best technology we had, the physician couldn’t find a heartbeat either. It’s probably the hardest job an OB doctor has, telling the expectant parents that their worst nightmare was their new reality. My wife was pregnant with a fully formed baby, and there was no sign of life.
I’ll never forget the absolute sorrow at that moment. I’d been in the exact same situation as a caregiver, but it was entirely different to be on the other side of it, to say the least. I have relived it hundreds, if not thousands, of times in my mind since, and I’ll never forget or stop appreciating the compassion shown to us on that day. It reverberates and revisits and is more powerful than people (including doctors) realize. Every carefully chosen word, the reassuring tones, comforting touches, even the moment of silence when hope was lost, mattered deeply to us. It matters still. It will always matter. The pain of our loss is forever intertwined with gratitude, and it helps. When all is bleak, you search for any small light and focus on it.
Patients and families may not remember a doctor’s or nurse’s name or face, but they will remember the smallest comforts we offer. Those moments are part of the story. Kenneth B. Schwartz, cancer patient and founder of the Schwartz Center for Compassionate Healthcare in Boston, said that compassion “makes the unbearable bearable.”
If I hadn’t had the experience of losing a son, would I be as convinced that compassion always matters? I can’t say. But I knew I approved of the consultant’s recommendations, and that I needed to get our entire health care system on board. On a human level, I hoped to lead a team that always gave patients and their families the same care and compassion that my wife and I received that day. I also had a business mandate to make our system more efficient and profitable. Let’s face it: the bottom line does matter. And if compassion could help us be more profitable, it’d be a win-win. The powers that be at Cooper believed it would. They expected me, their brand-spanking-new CMO, the youngest on record, to make it happen. If I didn’t, they might want to kick themselves for hiring me.
I had a simple solution to a complicated problem: call Steve.
I wish that all of life’s problems could be solved by calling Stephen Trzeciak (maybe they can?). This one definitely would. Along with being the co-author of this book, Steve is an intensivist (intensive care specialist) and was the head of critical care medicine at Cooper. His reputation as “the science guy” is well earned; he was our number-one National Institutes of Health (NIH) research grant recipient, the most published faculty member, our star researcher, our very own Super Nerd. Not only that, when I was just out of med school and a resident (a doctor in training) at Cooper, Steve was my attending physician (my teacher). We went way back. But even if we didn’t have a professional history and friendship, I would have gone to him first to solve this problem.
My logic was, Who else can turn the minds of our academic staff but its most academic member? If Steve could harness his nerd power and get an avalanche of research that proved compassion would make our system run better than it had in decades, we’d have a stronger leg to stand on than just “the consultant said so.” I knew we had very strong physician leaders across the health system who would follow the data and lead their people to do the same. My intention was to weaponize scientific evidence. We had to build a data bomb and drop it on the doubters. Steve would be our Oppenheimer.
Stephen Trzeciak here. Steve is fine.
Mazz called me in to talk about a new research project, a deep dive on compassion, empathy, kindness—anything and everything that fell under the umbrella of Not Being a Jerk—in the realm of health care. He said, “You’re the science guy. Can you take this list of mushy recommendations and science it up, give me evidence that I can take to the medical faculty that being compassionate will help the bottom line?”
My first thought was: “Okay, I wasn’t expecting that.”
Second thought: “Do people really call me ‘the science guy’?”
I call myself a “research nerd” all the time, because I really do love to start with a hypothesis, do experiments, gather data, and draw conclusions. The scientific method is how I approach just about everything in my life, especially my work.
At that time, my research had been focused on resuscitation, the science of almost dying. I had an NIH grant to study the optimal level of oxygen in the blood to avoid brain damage in cardiac arrest patients who’d been resuscitated via CPR and electric shock paddles (“Clear!”). But this research is probably only interesting to about 5 percent of doctors and few other people. As my research career evolved, I felt an internal need to put my energy and expertise into research that’d be meaningful across all specialties, not just my own. But I was stumped to figure out one subject that would be impactful for any specialist, primary care physician, or surgeon.
Compassion covered the ground on that score, so I found myself warming to Mazz’s ask.
Beyond that, I felt a personal yearning to dig into this vein. Mazz didn’t know that I’d been wrestling with some frightening and upsetting thoughts lately that touched on the subject of caring about and for other people.
Some quick background: I do critical care. In the intensive care unit (ICU), I often meet people on the worst day of their lives. My patients are as close to dead as you can be without actually being dead. Technically, I don’t really “meet” many of my patients because they’re usually unconscious when I show up. One thing I have learned after twenty years working in the ICU: life is fragile.
One day I had to tell a single mom that her nineteen-year-old daughter—her only child, best friend, and the center of her universe—was never going to wake up again.
On the drive home that day, I thought the unthinkable: I don’t know if I can do this anymore.
I was numb. Burnout is as common as the cold among health care workers. It’s real, and it’s heavy. The main symptoms are depersonalization, emotional exhaustion, and a dark feeling that no matter how hard you try, you can’t make a difference.
I was batting three for three there. I’d read that burned-out doctors were twice as likely to make medical errors. I knew quite well that medical error was a leading cause of patient death. Burnout played a significant role in doctors having one of the highest suicide rates of any profession.
I could barely admit it to myself, but some part of me feared that I was heading down a dark road and that I desperately needed to change direction, and soon. My poker face was glued on tight; my colleagues had no idea just how burned out I was. Quitting wasn’t a serious consideration. I have four kids and a mortgage, and being a doctor pays pretty well. But this problem had to be solved, or I might put myself and others at risk.
I did what I always do to solve a problem: science it. The best research on how to relieve burnout symptoms said to take nature hikes, do hot yoga, get a meditation app, take a vacation. Basically, to be a better doctor, I was supposed to get far away from the hospital and patients.
Escapism is built upon the belief that if health care providers spent less time caring for patients in favor of more self-care—“me time”—that burnout would evaporate, and good cheer would miraculously replace it.
Well, I wasn’t buying it. It did not compute. The answer to workplace burnout could not be to run away from the workplace. How was that a sustainable strategy for me, as the head of my department? Something had to change fundamentally at the point of care to reverse my, and anyone’s, disconnection, emotional exhaustion, and hopelessness.
At this critical point in my career, when I was trying to figure out a way to save it, Mazz tossed me a lifeline (although I didn’t realize it at the time). If nothing more, our side project gave me something to think about besides my burnout.
Empathy: the ability to understand and share someone else’s feelings.
I started with some key questions: What are the physiological and psychological effects of compassion and empathy? Can the effects of Not Being a Jerk be measured?
My scientific approach was to use a rigorous methodology, and not allow my personal feelings to influence my research. Along with being a doctor, Mazz is a lawyer too; he knows how to make arguments. I wore my agnostic scientist cap and remained unbiased.
Our exhaustive review of the scientific literature began on PubMed—it’s the Google for health care. What Mazz and I thought would be a trickle of research turned out to be a raving, overflowing river of it. One study led to another, and another. In all, we reviewed more than a thousand scientific abstracts. We gathered the most relevant into what we affectionately call The Curator, a supergeek spreadsheet of data that grew from a handful of research studies to more than 280. No one had ever compiled all the research on this subject in one place before.
At the time of their initial publication, people who read these papers on the effects of compassion probably found them incredibly interesting and perhaps also very impactful. They made ripples in the water, and some studies probably made a substantial splash. But with the methodology in our review—that finally connected all of the key studies—the ripples and splashes came together to form an unmistakable tidal wave of data that could potentially transform health care.
I’ll condense a year of study into four words: Compassion moves the needle.
Doctors’ and nurses’ compassion was associated with better patient outcomes in almost every aspect of health care, from decreasing a patient’s perception of pain to counteracting stress-mediated disease, speeding recovery from serious illness, increasing patient adherence to treatment—the list goes on. Suffice it to say, Mazz now had his data bomb to drop on the old-school academic faculty members. They couldn’t deny the overwhelming evidence that compassion would boost the metrics he’d been asked to improve. Mazz and I both knew these physicians and their ability to change their management of patients based on evidence-based medicine. They prided themselves on providing the best practice in medical care. Now we had the data to make the case for a change in the approach to patients based on science—with data that used the same rigor in its production as the medical journals they all read and rely upon for technical excellence.
Along the way, as I read study after study, I felt a stirring of hope. The evidence was clear: the cure for my burnout was not to escape. I could boost my resilience and protect myself from burnout by making deeper human connections.
When I started medical school in 1992, I remember being taught the strategy of not getting too close with patients or their families. Not connecting or caring too much, my teachers said, was an emotional shield. Mazz describes this lesson as a part of “the hidden curriculum” that doesn’t appear in medical textbooks. But it’s learned by medical students through socialization with senior doctors in the halls and on-call rooms of teaching hospitals. The thinking was that too much compassion, too much caring, would overwhelm, along the lines of “Don’t get too close, or you might get bitten.” Here is the problem: when you actually look into the scientific literature, you see a different signal.
Copyright © 2022 by Stephen Trzeciak and Anthony Mazzarelli
