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Join Drew Remignanti, an emergency physician, as we delve into the intersection of compassion, health care, and spirituality. Explore the vital role of compassion in medical care, the challenges of balancing health care as a service versus a profit-driven industry, and the significance of integrating spiritual well-being into medical practice. Drew shares profound insights drawn from his vast experience, offering valuable guidance for health care professionals and patients navigating the complexities of modern health care with empathy, humility, and trust.

Drew Remignanti is an emergency physician.

He discusses the KevinMD article, “The compassion crisis in U.S. health care.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Drew Remignanti. He’s an emergency physician. Today we’re going to talk about the KevinMD article “The compassion crisis in U.S. health care.” Drew, welcome back to the show.

Drew Remignanti: Thanks for having me back, Kevin, I appreciate it.

Kevin Pho: Drew’s been on multiple times. Go to KevinMD.com/podcast to hear his story and prior episodes. But today let’s jump right into your most recent one, about the compassion crisis in U.S. health care. For those who didn’t get a chance to read it, what’s this one about?

Drew Remignanti: Well, I took some of my direction from this excellent book. I’ve written a book myself, which is why I’m writing these articles and appealing to you to show them. My book is called The Healing Connection: A Partnership for Your Health. I’ll show that there, if you don’t mind.

But in the midst of researching my book, I almost stopped when I read a book called Compassionomics, which came out in 2019, by Drs. Trzeciak and Mazzarelli, in which they have a highly science-based argument for why compassion not only is helpful but is a necessary part of health care.

And I came to the same conclusion they had come to, which is, there is not enough compassion in health care, and we don’t just do it because it’s a nice, soft sounding, happy, feel-good feeling. It actually promotes greater health and greater longevity. You’re less likely to get sick and die if you’re treated in a more compassionate fashion.

Kevin Pho: People assume that compassion goes hand in hand with health care today. So according to the book Compassionomics, or your own definition, what exactly does compassion mean to you?

Drew Remignanti: Well, it’s taking the time to let people know that you care about them directly, you’re not just interested in their biomechanical problems or biomedical problems, you’re interested in the totality of their health, and you’re willing to put yourself out.

My own definition of love is that you temporarily, at least, make somebody else’s welfare above and beyond importance to your own. And so I think as physicians we show a form of love to our patients every day when we stop everything else that we’re doing and thinking about, and we concentrate on what is important for that person in that moment. I think when people can sense that from you, they sense that you have some compassion for their predicament.

Kevin Pho: And in today’s health care system, profit driven, business oriented, tell us the role of compassion in today’s health care system.

Drew Remignanti: Well, it’s minimized, basically, because, as I write in the book, that dollar-driven decision making has become ascendent in health care, and patient-centered decision making has taken a back seat to that. It’s an unfortunate state of affairs, but there’s no denying that. And I think we need to reverse that trajectory that we’re on, which is the reason I think they wrote their book Compassionomics, and why I wrote mine, to try to reverse that trend.

And it would be different again if it just was something that sounded nice and made you feel well in the moment, but it literally affects your mortality risk. I quote from many studies in my book showing that being treated in a compassionate and more meaningful way by the health care individuals that you’re interacting with can cut your mortality risk in half.

It would have been interesting if it was just a five or 10 percent reduction in mortality. You’d say, well, that’s kind of interesting, but so what? Literally study after study, I came across close to a dozen, I have a half a dozen in my book, which show the mortality rate is cut in half by people who are treated in a more compassionate fashion.

And when we basically get outside of our biochemical selves and get into the whole model that was introduced by George Engel back in 1977, that we are a biopsychosocial species, and I would add spiritual into that, which Dr. Engel did not have at that moment, we are not simply biomedical individuals, we are biopsychosocial individuals. How we interact with each other, and getting out of our own isolated interests, is healthy for us and prolongs our lives.

Kevin Pho: You’re very familiar, of course, with the emergency department. Tell us examples or stories of how compassion can play such an important role in the emergency department, and how the business pressures that affect the emergency department take away from that compassion.

Drew Remignanti: Well, what we hear in the emergency department is, how productive are you being? And I would like to point out that there are no products in health care. There’s either medical advice and interactions that are effective and excellent, or there are ones that are less effective and less excellent.

But from a business point of view, the bean counters, the business people, just want to know how many interactions you’re having, not the quality of it. And the writings we’re talking about, both Compassionomics and my own, and the studies, show that the quality of the interaction is key to creating the result that you want.

Kevin Pho: And according to the administrators, compassion really can’t be quantified. Or just to put it another way, there is no revenue in compassion.

Drew Remignanti: No, it’s just soft. You can’t measure how much compassion there is in an interaction, and you will never see an immediate, I shouldn’t say never, but you rarely see an immediate result from a compassionate interaction.

But you can down the line. And when you do these studies, these are massive studies, the ones I’m referring to, over the course of years upon years, with hundreds of thousands and even millions of observations, showing the reduced mortality when people feel they’re treated in a compassionate fashion.

Kevin Pho: Earlier on you talked about spirituality. So talk about that intersection between spirituality and compassion in medicine.

Drew Remignanti: That was interesting for me to discover, because when I was in medical school, I graduated in 1980, religion and spirituality were never spoken about in my medical school curriculum or in my training. I know you’re a little bit younger than me, Kevin. I think you graduated in 99, is that correct?

Kevin Pho: That’s correct.

Drew Remignanti: Was there religion and spirituality in your curriculum at any point?

Kevin Pho: I would say that there is no, I can’t remember any formal training.

Drew Remignanti: OK, because I did the research and showed that the vast majority of medical schools have incorporated religion and spirituality studies into their curriculum. And I read anywhere from 70 to 90 percent of medical schools, it’s talked about overtly, which is a good thing.

And I like the term spirituality better than religiosity, because spirituality is a broader term that doesn’t necessarily incorporate any one specific set of religious dogma, but it’s the whole concept of, there’s something above and beyond ourselves that we may not understand, that does affect our health.

Kevin Pho: So when it comes to spirituality, how can you incorporate that as part of the practice of medicine? So for instance, again, in the emergency department, which you’re so familiar with, do you incorporate elements of spirituality when you talk to patients?

Drew Remignanti: I don’t believe in my career I ever volunteered my own point of view, or said anything that had a religious or spiritual connotation directly to a patient. I’ve been on the receiving end of that a number of times, where people would say, well, I pray to God that I’ll get better, or that my mother will get better. And I’ve always endorsed, when people say that, I say, yes, I think that’s important.

But unfortunately, one of the things that a sense of religion and spirituality affects is our end-of-life thinking and our end-of-life planning. It was not unusual in the emergency department for me to interact with a family member who would come in and say, well, she would have wanted everything done. And it turns out the patient has metastatic cancer, end-stage metastatic cancer, and probably end-of-life planning was neglected to be discussed with that patient, for that patient to be able to say, well, gee, I really do, when I’m at death’s door, want to be intubated and placed on a ventilator.

So I think it’s something that we do need to address with our primary care doctors, especially as we reach end of life. The emergency department, the chaotic atmosphere, is not the best time to introduce those concepts, but to clarify them with your primary care doctor in advance of your emergency department visit was important.

Kevin Pho: So let’s talk about some paths forward. From an institution standpoint, hospitals and medical institutions, what are some things they can do to encourage more compassion, or create that culture of compassion that you say is missing today?

Drew Remignanti: I think they need to take this whole concept of metrics and measuring productivity out of it. At the end of my career I was 30 plus years in, I completed 40 years in full-time emergency practice, and even well into the 30 plus years, my emergency department director would be talking to me about, my productivity figures could be better.

And I’ve always found that a little bit offensive, to be told, well, how much time I need to take with the patient is dictated by the nature of their concerns, and sometimes the concerns are more complicated and require greater interaction time.

I made the commitment to myself that I was going to practice medicine to my own standards, even if it meant that I made my department director dissatisfied, which I know that I did. And I was hoping to finish my career before that ended up with me being fired because I wasn’t productive enough. And fortunately I was able to do that.

So we basically need to put medical decision making back in the hands of people who are committed to patient welfare based decision-making, and not dollar driven decision-making. It’s going to be a large task, a gargantuan task, in the words of Jack Wennberg, who wrote a book about that. But if we don’t do it, it’s not going to self-correct.

Kevin Pho: So just to be clear, you pushed back against the emergency department administrators who said that you weren’t productive enough. What exactly did you do?

Drew Remignanti: Basically said, essentially, that in the emergency department some things are fast and some things are slow, and I need to make my own call about when I need to slow down.

Time spent with patients is a metric that is never measured as a positive thing, but time spent with patients definitely contributes to the quality of the interaction, which contributes to the patient’s knowledge of their condition, contributes to their ability to understand what they should be doing going forward, that results in greater adherence to a plan, results in greater health and reduced mortality.

Again, study after study, people who were more adherent to a treatment plan have better results. And you might say, well, that’s no big deal, it just means good medicine works. But when you look at the studies more carefully, when they can do comparison studies with placebo arms, people who are more adherent to their placebo have reduced mortality as well.

So there’s something about the quality of the interaction with somebody who you believe cares about you, who gets you to care about your own health. And that healing connection, which is why my book is titled the way it is, that healing connection is life affirming, health and mortality reducing. That’s what the science tells us.

Kevin Pho: Do you have some advice for individual physicians, because they’re caught in the middle, right, between the administrators who want to push revenue, push metrics, push profit, and their core of why they became physicians in the first place? And there’s that tension between compassion and metrics. What are individual physicians supposed to do in that situation? Give some tips and advice for them.

Drew Remignanti: One of the things I did say out loud in one of these administrative meetings was, I practice to my own standards. Which was easy for me to say when I was 30 plus years in, a little bit harder to say if you’re a younger doctor, that you say, I practice to my own standards.

But you do need to develop your own standards about how much time you think a specific interaction takes. And if that upsets the system, well then it upsets the system, because that’s what contributes to burnout. And I like the term moral injury even better. That’s what contributes to the moral injury of health care, when you know you’re cutting corners and you’re not giving patients what you know they need based on the time that you’re with them.

So if you start to compromise your own standards and your own moral judgment, you’re going to not have a long career in health care, because you can’t do that to yourself day in and day out and survive and practice well.

Kevin Pho: I think patients and physicians and health care workers are on the same page in terms of the fact that we need to spend more time with each other, but we don’t. So I think we have the same incentives to want to spend more time, but we don’t have the power to institute that. Health care administrators, whether at the hospital, pharmaceutical company level, or health insurance companies, they have the power to change things but they don’t have the incentive to change things, because they know that time is money, and the old saying, and so they want to reduce the amount of time that patients and physicians have to spend with each other, unfortunately. And they’re doing a very good job at reducing that time.

So that tension between doctors wanting to spend more time with patients and administrators who actually want doctors to spend less time with patients, who’s winning that battle?

Drew Remignanti: Well, we’re clearly losing. Health care workers are clearly losing that battle. All we could do is, everybody could vote with their feet. We could say, OK, I can’t work here any longer, I’m going to go somewhere else. And I did leave a couple of jobs because I didn’t feel that they were compatible with the way I wanted to practice medicine.

But that’s a big-time decision, to leave your practice, because it may mean moving out of the geographic area in which you live. And very often, since private equity has taken over so many hospitals and emergency department groups, there’s often non-compete clauses in your contract saying, well, you can’t stay living where you’re continuing to live and work in a cross town hospital, or a hospital within a certain geographic area, because your contract says you’ve agreed not to leave this hospital and go to that hospital. So you’re sort of over a barrel.

We have to be willing to, if necessary, leave our positions, I think, as health care workers, and say, I can’t work with this institution if they don’t allow me to practice the type of health care that I think we need to practice.

And we need to do the same thing as patients. And I think as patients we probably have more power than the physician does, because, if you have an interaction in my emergency department, or you’re hospitalized, and they send you one of those surveys, I would tell everybody, either don’t fill them out at all, or better yet, get on the phone and say, I need to speak to the hospital administrator, because I got this survey and I think it doesn’t really address the things that I think are important.

The things that I think are important as a patient, that I observed when I was in the hospital, is, none of the health care workers seem to have the time to spend with me that I needed to have in order to feel better, and I’m willing to stop coming to this hospital if I don’t get the time I need to address the concerns I have. That might get their attention, the dollar-driven decision makers.

Kevin Pho: We’re talking to Drew Remignanti. He’s an emergency physician, and today’s KevinMD article is “The compassion crisis in U.S. health care.” Drew, as always, we’ll end with some of your take-home messages to the KevinMD audience.

Drew Remignanti: Again, I would say, for the people working in health care, evaluate what you want to get out of your career and what you think your patients need from you. And if it is more time, then you need to rock the boat and spend more time with them, and show that sense of compassion.

Or actually, compassion is a more benign word than love. It’s truly love, which is, you, in the moment of interaction with the patient, their welfare has to become more important than your own welfare, more important than the welfare of your department, of your hospital, your institution. So the welfare of the patient has to become priority number one.

And from the patient point of view, you need to take your own welfare more seriously than we are currently doing, and make a commitment to following a healthier plan with your primary care doctor. Therefore you’d avoid seeing me in the emergency department, if you can.

Kevin Pho: Drew, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Drew Remignanti: Thanks for having me, Kevin. I really appreciate it.