S5E15: Transcript
Compassion in Healthcare & Flourishing
with Dr. David Addiss
 

Tavia Gilbert: Welcome to Stories of Impact. I’m writer/producer Tavia Gilbert, and every first and third Tuesday, journalist Richard Sergay and I bring you conversations about the art and science of human flourishing.

In today’s episode, we welcome Dr. David Addiss, an expert in public health and preventive medicine. Dr. Addiss has spent his career not only thinking about science, but about service. In his early career, he spent years caring for the health of migrants in the San Joaquin Valley of California, then later worked for nearly two decades the Centers for Disease Control in the Division of Parasitic Diseases, where he focused on controlling and eliminating diseases not found in the United States, but in communities of neglected people largely in the tropics.

Dr. Addiss surely could have pursued an easier and more lucrative medical specialty than public health. So what inspired him to choose to spend his career caring for the needs of underserved and neglected people?

Dr. David Addiss: I was raised Baptist. My father was a Baptist minister. When I was nine years old, a man named Dan Fountain, who was a medical missionary, a surgeon, in the Congo, came and stayed in our house for a couple of days, and he was the most amazing man I'd ever met. And from that day onward, I wanted to grow up to be like Dan Fountain. 

He had started as a surgeon, a missionary surgeon, and he realized very quickly that he was having limited impact on health conditions in the village and the area where he was working. So he was drawn to public health out of a sense of needing some other tools to actually improve health at the population level. 

Dan focused largely on the surgery and the public health programs that he developed, but he was motivated out of a sense of service that came from his religious faith. And he understood, I think in many ways, the faith dimensions or the supernatural understanding of disease in the people that he worked with because of that.

And he also went to Johns Hopkins, and so I wanted to follow in his footsteps and get trained there.

Tavia Gilbert: Dr. Addiss’s decisions as a medical practitioner have always been guided by his faith — whether that faith is religious or spiritual.

Dr. David Addiss: I grew away from the church in high school and college, but have always had a strong connection to that faith commitment. I was drawn to a contemplative religious awareness, maybe 15, 20 years ago, through the writings of Thomas Merton and other contemplative Catholic writers — Henri Nouwen — and have also done some training in Buddhist chaplaincy. 

So I have an eclectic background, but clearly faith and the religious sensibility really influences my understanding of the world and what I do in the world.

Tavia Gilbert: Dr. Addiss has turned his focus today to the role of compassion in healthcare. Along with several colleagues, Dr. Addiss is a Templeton World Charity Foundation Awardee of TWCF’s Grand Challenges for Human Flourishing. His team’s focus is to discover the meaning and mechanisms of human flourishing in the context of suffering; to understand how compassion alleviates suffering and promotes flourishing in healthcare settings; and to develop large-scale evidence-based programs to promote compassionate, high-quality national health systems. 

Though his career has been guided by his willingness to offer compassionate care to his patients, he’s only recently begun to consider compassion as a scientific researcher.

 Dr. David Addiss: I suppose that I had thought about compassion in my clinical work. It was part of it, in a sense, it was embedded in it. But I hadn't started thinking about compassion as a motivating force for the whole field of global health, which I have come to see as a sometimes uncoordinated effort to alleviate suffering, and now also to promote flourishing.

I didn't really start thinking about compassion in medicine or compassion in global health until I was a Program Officer at the Fetzer Institute, and I had left the field of medicine and global health. I started reflecting on the role of compassion in my work as a global health physician, and I realized that I’d rarely heard that word in the halls of CDC. And when I would go back to visit my colleagues at CDC, I would ask them over dinner, can you tell me in one word, why are you doing all of this work? What motivates you? 

When they were willing to play that game, they would whisper words that I did not hear them say in the halls of CDC. Words like “care,” “compassion,” even “love.” And the disconnect between what seemed to be motivating all of this work at the personal level and what was in our discourse really struck me. And it was that disconnect that kind of motivated my interest in exploring this hidden gem of compassion that lies at the foundation of a lot of this work.

Tavia Gilbert: When Dr. Addiss suffered his own health crisis — a herniated disc requiring surgical intervention — and he experienced medicine as a patient, rather than a practitioner, his understanding of and interest in the role of compassion was sparked.

Dr. David Addiss: I had gone without surgery for several months, and the surgery was successful in a sense, but it was a rough process of healing. When I was in the hospital, I got excellent surgical care, clinical care. But I didn't really experience compassion, except from one phlebotomist who would come in in the middle of the night, usually two in the morning, ask me to put my arm out so she could draw blood. 

Our encounter every night was about two minutes, but something about her presence communicated to me a sense that I was being seen, communicated a sense that she saw me — even though her job was to draw my blood — she saw me as a person, and that made a big difference to me in terms of how I saw myself and was addressing the suffering I was experiencing.

And so, as I reflected on flourishing, and particularly the idea that flourishing is a sense of all things going well in all domains of your life, I thought, well, if that's true, how many minutes of my life will I be truly flourishing? Because there's always something that could be better. And I started wondering about flourishing in the context of adversity. 

And as a physician, I've known people who were at the end of their life, perhaps in great pain, and yet they were flourishing, they were fully alive. And also people who seemed to have everything that I was searching for or looking for as a professional physician, who seemed miserable. 

So this dialectic between suffering or adversity and flourishing became alive for me, and I became curious about, particularly in the healthcare context, the role of flourishing in alleviating suffering, and particularly, the role of compassion and compassionate care in transforming suffering into flourishing. And so that was the genesis of the idea of, can we examine compassion as a pathway to transform suffering that brings people in to seek medical care into more fully flourishing in their lives?

Tavia Gilbert: Dr. Addiss is now at the forefront of flourishing research around compassion — research that has the potential to revolutionize the way healthcare in America is considered and delivered.

Dr. David Addiss: There is a science of compassion that is also flourishing and starting to develop and to become more robust. And I think the scientific evidence showing that compassion and how it's expressed actually does have a healing effect is important in patients' outcomes, particularly if we look at the outcomes from a perspective of flourishing. That it's not a matter of physical science versus science of these maybe softer or more intangible qualities, but I think we need more science to bring compassion into the mix and look at the effectiveness that it has on health outcomes and flourishing. 

In my mind, it's not a matter of reducing the clinical science or of trading technical excellence for compassion. It's a matter of infusing compassion into the work. The science are the tools that we have, but what is it that motivates the use of those tools? What is it that guides those tools in a wise way, that actually addresses the needs of the person and not just alleviation of a certain disease? 

So it's a practice, I think. There's skills that are needed to allow physicians, nurses, the ability to apply those technical skills but also see the person in front of them. There might be contemplative techniques — pausing before each patient, very simply, and saying, I'm going to set an intention to see this person while I'm filling out my electronic medical records.

Tavia Gilbert: Drawing on his personal experience of how rarely compassion was offered him during his surgical recovery, and how much of a difference receiving it made to his healing, Dr. Addiss recognized that there’s something fundamentally missing, something that is broken, in the practice of modern Western medicine. If a key component of human flourishing is health, then medicine should help people become healthy and flourish. But in his experience as both doctor and patient, that has not been the goal of Western medicine.

Dr. David Addiss: I think the system's in crisis now. I think we've not been mindful about how we bring technology into the relationship between clinician and patient. We have a for-profit motive that has created distorted incentives. Perverse incentives, really. And we have a mechanistic system that sees its goal as providing treatment, providing medication, maybe bringing people back to some level of functioning that's acceptable to the system. We don't have a view of medicine as something that is to promote flourishing. It's an anemic view of what medicine could be.

And I think some of the larger systems that we're struggling with, the for-profit healthcare systems, are generally, ultimately incompatible with the full potential role of medicine in promoting human flourishing. If the incentives are to provide wealth for the shareholders, that acts against the investments that are required in medicine and healthcare.

It's very clear that compassionate care has benefits for patients, for providers, and even for the system. So it is a bit of a mystery as to why, given that evidence, systems haven't run to become more compassionate.

By reimagining medicine or healthcare as promoting flourishing, we move beyond just taking care of the physical domain and also begin to ask, how do we address, in what way can health systems actually address other domains of flourishing, like reimagining meaning and purpose for people who have a stroke or a condition that limits their capacities that they had previously? How do we promote social relationships? The domain of financial stability? Right now, our health system is destabilizing people financially. It's bankrupting them. 

So by envisioning healthcare as something that is concerned with something beyond the physical, to the mental, the social, use the word spiritual if you like, helping us reframe who we are as people after catastrophic illness. What is our meaning and purpose? What elements of compassionate care do we need to promote? Can we also create environments that allow patients to receive that? And obviously, trust is going to be a huge element there in allowing them to receive compassion. 

Virtue — I think that's a word that we shy away from in our current sort of secular discourse. I think that's an important word. The great thought that has taken place around issues of compassion, virtue, dignity, that we need to understand at a new level now. I think grasping and bringing these concepts and living these concepts is going to be really important for promoting flourishing in healthcare.

It would potentially transform where we invest our funding, where we invest our efforts in medicine, so that we're actually promoting flourishing rather than, in some ways, largely either ignoring flourishing or diminishing it.

Tavia Gilbert: If we are to transform healthcare into a practice designed to help people flourish, if doctors are to shift from whispering about compassion to confidently embracing that virtue as a part of their medical practice, then we might start by defining what compassion actually is.

Dr. David Addiss: Compassion is what love does in the presence of suffering or in response to suffering. So we tend to view compassion as having three different elements or components. First, to have a compassionate response to suffering, you have to be aware that it exists. You have to have information — or in the context of public health, data — coming in to alert you to the fact that there are human beings who are suffering or in distress. If we turn away from that and say, “I don't wanna be informed, I just wanna live my own life,” we're not going to have a compassionate response to that suffering. 

Ideally, that awareness of suffering in another human being or another sentient being evokes an emotional response. We can call that empathy. The feeling of what the other person is feeling, feeling someone's pain. And that, ideally, because we want to be in relationship to others, we want to help others, we want to preserve life and support it, that emotion leads us to take action to alleviate the suffering. And so compassion would have these three elements of awareness, empathy, and action, and all three of those elements are important. One shorthand for compassion might be that it's empathy plus action, or at least the desire to act.

Tavia Gilbert: What else has Dr. Addiss learned from his research about compassion — awareness, empathy, and action — in medicine?

Dr. David Addiss: The ability to receive compassion actually promotes flourishing — self-compassion and the ability to receive compassion from others. And the ability of compassion from others was linked to decreased loneliness. And that that decreased loneliness was a mediator in improving quality of life, social quality of life.

Action may be being present to someone who's dying or needs someone to listen to them. So the action itself is not some grand project. It may be simply presence, and in many situations — palliative care, hospice care — one’s presence is the action that matters the most.

Tavia Gilbert: In fact, he says that compassion doesn’t benefit just only the recipient.

Dr. David Addiss: We tend to think of compassion as giving something and receiving something, but in those moments of deep compassion, the giver and the receiver seem to blend together. There's a relational element that kind of transcends that duality of giving and receiving.

Tavia Gilbert: Though he recognizes that compassion is not included in the standard of care throughout all specialties of medicine, Dr. Addiss can point to some practice areas that integrate taking the time to offer compassionate care into their day-to-day work.

Dr. David Addiss: What's been exciting is to see how much already in the last few years flourishing has started to infiltrate the language and the literature of fields of medicine. Palliative care is one area that highlights compassion and incentivizes that time, as well as working with patients and families to help direct the course of their treatment. 

For example, rehabilitation medicine, where they're calling for a reimagination of the whole rehabilitation project to promote flourishing. Rehabilitation medicine is now embracing, in some ways, flourishing as a goal of its work. It's not just patching people up and rehabilitating to somewhere close to where they were before, but what new dimensions of their life can be developed so that they actually flourish, even while perhaps limited? So those might be two bright spots. 

I don't think, though, that continuing in the way that we’re continuing now, will make healthcare any better. I think it's going to get worse. So I think what's required is for some people who are imaginative, creative, perhaps with some foundation funding, to demonstrate what this actually looks like in practice and to keep close attention to the economics of that. I would gather that if we're looking at population health and we're looking at health and wellbeing of populations, that our current system actually is very inefficient and very costly. We could achieve better results with less cost if we were not constrained by the current incentives of a for-profit healthcare system.

Tavia Gilbert: How does Dr. Addiss believe compassion can be better integrated into medicine?

Dr. David Addiss: If we want to develop a larger demonstration project to bring compassionate care more fully into a health system, we want to know what we're measuring, both in terms of suffering, the dimensions of suffering, but also the dimensions of care, compassionate care, and then flourishing.

We need to understand the different forms of suffering or motivations for people seeking healthcare. We need to understand the elements of compassionate care as it's currently envisioned, but then also we want to look at how compassionate care might influence the different domains of flourishing, not just physical healing.

We’re engaging in conversations with people that I would call exemplars, people who are known or health systems that are known for their compassionate care. We want to understand — what makes that work? What motivates them, what sustains them in that work? What challenges do they face? What advice might they have for others, for us, if we want to reimagine healthcare as a compassionate enterprise. And so we want to hear from them, people who are working in the field, in a sense, and who have a reputation for delivering compassionate care.

Tavia Gilbert: One of the things Dr. Addiss has learned from his research is that there is a direct link between time and compassion. While past generations of medical doctors, or indigenous caregivers may have had less technology with which to care for those in their communities, they did have more time and mental space.

Dr. David Addiss: Are we more or less compassionate as doctors and nurses than we were a hundred years ago? Certainly, before modernity, the tools that we had to heal were less, and a sense of compassion may have been more important as a proportion of what someone could bring to the healing, to the bedside. 

Healthcare, I think, was more integrated into societies. The role of the healthcare provider was, I think, clearer. Less technological, less fragmented. And so there was one or maybe two people who you'd turn to for health-related conditions. It might have also been at some point the priest, and so there might have been sort of the same person who addressed mental, physical, emotional, spiritual, health threats. 

It's much more fragmented now. And I do think that the one element that was much more prevalent there was time. And there's a classic study from the 1970s called The Good Samaritan Study, where the investigators went to Princeton Theological Seminary, and they instructed the students to either develop a talk on the Good Samaritan or develop a talk on another topic. And then they asked both groups to go across campus to another room where they were going to reconvene. And half of each group, they said, "You need to get there in 10 minutes," or, "Take your time, we'll reconvene in another hour." 

Along the way, there was an alley. And in that alley was an actor, shabbily dressed, obviously in pain. And the students had to walk by. Being assigned to give a talk on the Good Samaritan made no difference as to whether they stopped. Being given the luxury of time made a huge difference. I think those who were given a longer time to get to the other part of campus were six times more likely to stop and offer help. 

So we're trying to force compassion into a timeframe in which it doesn't work. So I think that that element of time is very important, and we have to factor it into our systems. So in a sense, there might not have been a greater inner motivation or desire to be compassionate, but the conditions in which the practitioners in the pre-modern age practiced were more conducive to offering compassion.

We need to think more deeply and more intentionally and be more present to the human dimension of medicine that is so easy to get lost in the busyness of clinical care or public healthcare. So I would say perhaps it's a matter of remembering, it's a matter of recalling why we're here on a day-to-day basis, and it's a matter of providing those contemplative, meditative, maybe centering skills that keep us from getting lost in the busyness of the moment and the technological aspects of our work, the mechanical aspects of our work.

It's not just a matter of teaching nurses and doctors how to meditate or to give them compassion meditation or resilience training. What's needed is a much larger, systemic change. So when we think of compassionate healthcare, we're thinking not just about the patients, we're thinking about, what does it require for the providers to flourish? What is required for the systems also to flourish? 

Tavia Gilbert: Dr. Addiss believes that if today’s doctors recognize the importance of taking — and making — time, if they can reconnect with the reasons they were first drawn to care for others, there is the possibility for compassion to be more deeply and effectively woven into modern medicine.

Dr. David Addiss: I'm hopeful. And I see, every day, I talk to amazing people who are doing incredible work, compassionate work, and they're doing it in a way that gives me hope and inspires me. I'm inspired in the short term by colleagues and people I read about, and we have a very entrenched system. And so I'm hopeful in the long term, and I think we can make some demonstrable progress in the short term.

Tavia Gilbert:   I was so moved by Richard’s interview of Dr. Addiss, and at the close of their conversation, chose to share with him why his research about compassion in healthcare is so personal to me. I was born with deformed feet, I told him. My first corrective foot surgery was when I was just 7 months old, and between 7 months and 29 years old, I had well over a dozen major surgeries, requiring months of healing and rehab every time. 

The hospital was not a happy place to spend much of my childhood and adolescence, and the orthopedic surgeons who managed my care were not the best friends I would have wished for. My stories could fill a book; maybe someday they will. In fact, you can hear more about what I learned from so much physical suffering if you check out my TEDx talk (we’ll link to it in the show notes).

Though I had some pretty difficult times, physically and spiritually, there was one nurse who stands out. Though I don’t remember her name, I will never forget the nurse who came to check on me in the middle of the night and found me shaking and crying in the hospital bed, in terrible pain. I was maybe around 7 years old. That nurse didn’t rush off to the next patient, but wound up my stuffed koala bear music box, stroked my hair back from my feverish face, and sang along in French to the tune of Frere Jacques until I finally fell asleep. 

Like the phlebotomist who made Dr. Addiss feel seen, and who offered him a sense of himself as a whole being, rather than just a part of a body, that nurse had an enormous impact on how I sensed myself. I was more than just a foot — I was a whole person, deserving of tenderness. Over 30 years later, I can say that she made a profound difference in my life. She was a true healer, and her compassion, her time, and her love, will never be forgotten. Wherever you are, dear nurse, thank you.

We’ll be back in two weeks in conversation with Dr. Brie Linkenhoker, who, like Dr. David Addiss, is a TWCF Grand Challenges for Human Flourishing awardee. Her research is about the stories we tell ourselves, how these stories form, and how they influence behavior, wellbeing, and achievement.

Dr. Brie Linkenhoker: I look at science as an incredible human achievement. You know, it's a gift to humanity, because it is the best way we have of knowing about the world around us and about how our bodies work, how our brains work, the origins of the universe. Science is the best method that we have for knowing about the world. A healthy society can agree on facts. We can agree on what we know, but we can disagree on our interpretation. We can disagree about how those things came to pass or what we should do about them, but we should fundamentally agree on what we know. And that's not working right now. Our research on the stories that we tell ourselves about science really does suggest that, with a few changes in the way that we do science engagement, maybe we could get closer to that place of being able to agree on what we know and what we don't know about science, and then being able to disagree on what to do about it, or disagree on the meaning of it. I think that would help us flourish as a society.

Tavia Gilbert: If you appreciate the Stories of Impact podcast, please follow us, and rate and review the program. You can find us on Twitter, Instagram, and Facebook, and at storiesofimpact.org.

This has been the Stories of Impact Podcast, with Richard Sergay and Tavia Gilbert. Written and produced by Talkbox Productions and Tavia Gilbert. Senior producer Katie Flood. Music by Aleksander Filipiak. Mix and master by Kayla Elrod. Executive producer Michele Cobb.

The Stories of Impact Podcast is generously supported by Templeton World Charity Foundation.