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Can big bucks and training courses influenced by Tibetan Buddhist teachings solve the problem of physician burnout?
With support from the Dalai Lama, whose approving words encouraged a philanthropist’s generous gift, researchers at the University of California San Diego (UCSD) are building the $155-million T. Denny Sanford Institute for Empathy and Compassion. Sanford, a South Dakota billionaire with long-standing philanthropic ties to the San Diego area, has pledged $100 million; UCSD will provide the rest.
The money will, they hope, restore doctors’ faith and satisfaction in medicine and prepare them to better cope with their increasing demands.
The five-year effort is unique in its vision to better understand the neurobiology of empathy and compassion, UCSD officials said. Scientists will use fMRI to elucidate how these emotions are expressed in brain activity, test interventions designed to increase empathy and compassion on young medical students in IRB-approved clinical trials, and publish their results. For what works, they hope to expand use throughout the system.
The goal is two-fold: to help young physicians develop compassion and empathy for their patients, and for themselves. The latter is envisioned as the key to preventing burnout.
While some experts question whether such studies and training will yield useful information and make a meaningful impact on physician burnout — and whether all of this requires hundreds of millions of dollars — institute founders hope they will have an impact.
“We think that we can find ways to help physicians maintain empathy and compassion in spite of the challenges they face,” said William Mobley, MD, the new institute’s interim director and associate dean of UCSD’s Neurosciences Initiatives.
Wacky California?
Mobley, a Down syndrome and Alzheimer’s researcher, pointed to numerous studies in the neurobiology literature that demonstrate scientists’ ability to see levels of empathy and compassion in the brain. They can, he said, “not only identify those brain pathways — those brain regions that are activated when one is engaged in acts of empathy and compassion — but to realize that they are plastic and that training can actually enhance their activity.”
He knows that some neuroscientists and others working in burnout may laugh at the idea — especially one costing $155 million — or dismiss it as a “New Age” thing or just wacky California.
“There will be people who dismiss empathy and compassion and training as a lot of fluff … and question why somebody would put effort and energy into this because they think empathy and compassion are native attributes,” he said. “They don’t see how stressed out [people can be]. I hope they understand that our team is humbly approaching a big, big problem with the hope we can make a difference.”
Plenty of questions remain unanswered about the neurobiology of empathy and compassion, he said. There’s more to learn about the exact brain regions involved, and outcomes of the training can reveal how to strengthen those neurological pathways.
A long time brewing
For Mobley, it’s a dream come true. A decade ago, he came to UCSD from his position at Stanford University where he held leadership positions in neurosciences since 1997. Since meeting the Dalai Lama at Stanford, he said, he envisioned creating a neurosciences institute to study compassion and empathy.
Strategies to help doctors cope can be tested, he said, not just with objective measurement tools like fMRI, but also observed by how study subjects react: “what they say about how they feel about the challenges they face” before and after the interventions.
He pointed to an article in Translational Psychiatry that compared scores of self-reported burnout severity among medical professionals to measures of reduced activity in empathy regions of the brain to show the program’s goals can be accomplished.
So what empathy and compassion inducements will $155 million actually test? Increasing the length of appointments? Reducing documentation requirements? Hiring scribes? Removing prior authorization requirements?
Not exactly.
Learning empathy
The tools that will be tested have already been developed and are being taught through coursework from the Compassion Institute, a Palo Alto, California-based non-profit that spun off several years ago from Stanford University and is partnering with UCSD in this effort.
One of the Dalai Lama’s principal English translators, Thupten Jinpa, PhD, is the president and chairman of the Compassion Institute.
Asked how much of the $155 million will pay for the Palo Alto organization’s empathy and compassion training exercises, Mobley at first said it was “a small fraction,” and “a few percent.” Pressed for a dollar amount, he responded “I don’t think that’s relevant. The point is that we’re going to pay for their expertise and services.”
However, one line item in the Charitable Gift Agreement earmarks $6 million for “facilitation and dissemination of training modules, under the guidance of the Compassion Institute.” It’s unclear if amounts from other line items will go to the Palo Alto organization as well.
These exercises, which are influenced by Tibetan Buddhist teachings but don’t involve religious themes, are currently offered by the Compassion Institute to law enforcement officers, prison inmates, and the general public, but UCSD intends to tailor them for doctors and other health providers. The new center’s scientists will test them with reputable scoring systems like the Maslach Burnout Inventory or the Jefferson Scale of Empathy in medical students and later, UCSD physicians.
“We hope to create a product with them that they can basically make available to anybody anywhere,” Mobley said.
Money in, money out
Mobley at first said that UCSD will not be selling this as a product, but that the Compassion Institute will be able to market any enhancements or modifications made as a result of the project. The contract is “to work with us to make their training programs even more effective, initially focusing on physicians with the idea ultimately of a product that they would take around the world if they wish. We’re not the distributors.”
In a second conversation, when asked if UCSD would receive any money from sales, he said he wasn’t aware of any such provision, but couldn’t say for sure. “I don’t know that I can say that in a legalistic way and have that stand up,” he said. It could be that the exercises developed would have both UCSD’s and the Compassion Institute’s names.
He referred the question to the agreement’s memorandum of understanding, which UCSD has not released.
Compassion Institute’s modules were developed in part by Jinpa while he was at Stanford. Jinpa broke away from Stanford to start the Compassion Institute, which Mobley said “has kind of taken the license from Stanford” to provide compassion and empathy training, and now has “hundreds of people who are trainers all over the place.”
That’s why, Mobley said, UCSD is partnering with the Compassion Institute instead of Stanford’s Center for Compassion and Altruism Research and Education.
The modules UCSD intends to use include one or two hours of class work each week for six to eight weeks, plus individual empathy and compassion exercises participants do on their own. The Compassion Institute’s current “nominal” price to its clients, generally paid by institutions or the participants themselves, is about $395 per participant with discounted programs available for $100, said the Palo Alto Compassion Institute’s executive director, Katharine “K.C.” Branscomb.
A share of the $155 million will renovate space for the Sanford Institute, while other portions will create six center divisions, with some 20 directors.
About 6.5% of the money, or $10 million, will pay five-year operating costs of UCSD’s Student-Run Free Clinic, created some 20 years ago to provide basic medical and dental care for uninsured people who don’t quality for any other program.
That’s because those medical students — about 250 of whom volunteer at the clinic each year — will be the ones who receive the Sanford Institute’s compassion and empathy interventions and who will help to test whether the strategies actually increase their compassion and empathy, and reduce any burnout they may have during the high-pressure years of medical school.
No magic pixie dust
James Hallenbeck, MD, associate professor of medicine, emeritus, at the Stanford School of Medicine, and associate chief of staff for extended care at the VA Palo Alto Health Care System, has received and taught the Compassion Institute training programs. For the last year, he’s been working with the institute’s pilot model for health providers, which incorporates elements of mindfulness in its training for clinicians in a way to increase compassion and prevent or control burnout.
When asked how these sessions do that, Hallenbeck replied, “We would never promote this to say suddenly the electronic health record and the other challenges in your life, or anybody else’s, are suddenly going to go away.”
Rather, the sessions are geared to help clinicians better cope with stress, for example, more smoothly switch tasks from working on a medical record to answering the phone, or going from one patient’s room to another. They might learn to pause, take a moment to take a deep breath, perhaps while washing one’s hands between patients. “It helps chill them out for a second, and shift from the last patient to the next.”
Stresses come from many areas, Hallenbeck continued. It may be that a supervisor wants a patient discharged earlier to lower length of stay, but that puts pressure on the doctor to do something not in the best interest of the patient. It causes a kind of moral distress. The natural reaction is anger, “and you want to yell at that person,” Hallenbeck said. Compassion training helps that person see the other person as a victim of the same bureaucracy.
“Is it magic pixie dust? No. But it does soften the edges around that natural anger that one might feel if you realize the other person … has a lot in common with you.”
‘That’s a ton of money!’
Not everyone is convinced that UCSD’s ambitious plan will improve wellness for the physician workforce.
Susan Thompson Hingle, MD, past chair of the American College of Physicians Board of Regents and a leader of the ACP’s Physician Well-Being and Professional Satisfaction initiative, was asked for her impressions of UCSD’s project. She is the associate dean at Southern Illinois University’s Center for Human Organizational Potential, and for her, physician wellness is a keystone issue.
“That is a ton of money,” she said, expressing surprise. After reading UCSD’s project description, she added, “What is in this document isn’t very extensive or expensive.”
Asked how she would use $155 million to improve empathy and compassion and reduce burnout, Hingle rattled off a list of practical, real-world changes to see if they could remove what drives so many doctors to despair.
“One of the issues with our practice environment is that it’s really so productivity-based in that the more you see, the more money you make,” she said. She would look at replicating practice modules where physicians are on salary, and don’t have “the intense pressure to see patients in 10 or 15 minutes,” to see if “physicians who get to spend a lot more time with their patients, if their burnout is any less.”
Another strategy to try would be to reduce silly regulatory requirements, because even small details create annoyance and distraction. “Just this morning, I had to sign to have someone’s wheelchair tire fixed. I’m not sure why that needed a physician’s signature.”
The wrong test population?
Privately, some wellness experts were skeptical of testing burnout prevention interventions in eager, young medical students working at the Free Clinic, whose encounters with the profession’s stressors are limited.
The clinic engages about 250 volunteer medical students each year, but their time in the clinic is typically short — usually no more than 4 hours a week during their first and second years and no more than 18 hours during one month in their fourth.
Any decisions they make about patient care, for roughly 4,500 medical patient visits each year, are overseen by an attending. Their patients are largely uninsured, and some undocumented, with no other source for care. Though challenging to care for, they’re largely grateful for the help they get, said the clinic’s co-medical director, Sunny Smith, MD.
Far from being an experience that burns them out or drains their empathy, the Free Clinic is the reason students give when asked why they want to be a doctor, she said. “It’s where they see compassion in action … and where they feel connected with their purpose.”
Patient care includes going into a church, talking with patients “without a front desk (and) without financial barriers between them and their patients. They don’t have time pressures,” Smith said. They can just sit and talk with patients not just about their health, but also about what “biopsychosocial issues are going on, and how can you empower them, given the limitations they’re facing, and (help them) take control of their life.”
Moreover, students get plenty of support from attendings and clinic staff.
So, how do you test burnout prevention in a setting where it isn’t likely to affect study participants?
Smith responded that medical students do get burned out and lose empathy and compassion from other portions of their medical education, which can be extremely stressful, she said.
‘It’s an experiment’
Asked the same question, Mobley answered, “We’ll see; it’s an experiment. I don’t know the answer to your question. That’s why we’re doing it. We’re trying to figure out what works and doesn’t work, and this will be one of the variables: … Is what we’re doing making a difference in the lives of medical students and their patients?”
On the other side, some physician educators and leaders who have studied aspects of empathy, compassion, and burnout from a neuroscientist’s view see promise for the project, even if it doesn’t initially test strategies directed at the frustrating bureaucracy and time constraints affecting real-world physicians.
“If you want my guess, they probably will, after the first few million dollars are spent, test other interventions,” said David Eagleman, PhD, a Stanford University neuroscientist. “What if we have the monitor in the room or out of the room, or what if we have the [doctor] typing at an angle where you can see the patient versus not? … They will be well-positioned to move on to all of those behavioral changes that are super important things to test.”
Stephen Klasko, MD, president of Thomas Jefferson University in Philadelphia and an author and speaker on physician burnout, also was positive about the project. “I would do exactly what they’re doing,” he said. “The brain scanning they propose is very similar to what we do with PET scans to study stress.”
No one disagrees that burnout is a huge and growing problem among providers, with an aging physician workforce uncomfortable with new documentation requirements and a younger generation some believe are not willing or equipped to work as hard as their forebears.
Mobley said his team is not promising success, but they think they have a great chance for it.
And for those cynics who might giggle at the large amount of money for such an effort, he has a response: “My question to them is, do you have a more effective way of helping? If you do, go for it.”
2019-08-14T12:00:00-0400
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