One emotional task that often leads to catching distress is continually listening to someone’s worries. This problem has been called “compassion fatigue,” where a helper herself becomes overwhelmed by the anguish of those she tries to help. One solution for the helper is not to stop listening but rather to find emotional support. In a compassionate medical setting, people like nurses who operate at the front line of pain and despair need help to “metabolize” that inevitable suffering, rendering them more emotionally resilient. Institutions must make sure nurses and other staff have enough support themselves to be empathic without burning out.
Just as people whose work makes them vulnerable to repetitive stress injuries take stretch time-outs, those who do stressful emotional work can benefit from time-outs to calm down before reentering the fray. But such restorative breaks will never become routine unless the emotional work done by those in the medical professions become valued by administrators as an important, even crucial part of their task—one that needs to be done along with, rather than in spite of, other duties.
Typically the emotional component of health care jobs does not count as “real” work. But if the need for emotional care were routinely regarded as an essential part of the job, then health workers could do their jobs better. The immediate problem comes down to getting more of these qualities into medicine-as-practiced. Such emotional labor can be found nowhere in the job descriptions of health care workers.
Worse, medicine can be prone to the most common error in choosing leaders, what one wry observer noted as the tendency to promote people to their level of incompetence. Someone is likely to become a department head or executive on the basis of their technical excellence as an individual performer, such as a brilliant surgeon—without regard for essential capacities like empathy.
“When people are promoted to management based on medical expertise, not people skills,” notes Joan Strauss, senior project manager for service improvement at Massachusetts General, a famous Harvard Medical School hospital, “they sometimes need coaching. For instance, they may not know how to hold people accountable in a respectful and open way—without being a patsy on the one hand or Attila the Hun on the other.”
Studies comparing superb leaders with mediocre ones have found that the competencies that distinguish the best from the worst in human services have little or nothing to do with medical knowledge or technical skill, and everything to do with social and emotional intelligence.13 Of course, medical knowledge matters for health care leaders—but it’s a given, a threshold competence that every health professional must have. What distinguishes leaders in medicine goes far beyond that knowledge, into interpersonal skills like empathy, conflict resolution, and people development. Compassionate medicine needs caring leaders, ones who themselves can give medical staff the sense of a safe emotional base to work from.
HEALING RELATIONSHIPS
Kenneth Schwartz, a successful Boston lawyer, was forty when he was diagnosed with lung cancer. The day before he was scheduled to have surgery, he came to his hospital’s presurgery area and sat in a mobbed waiting area while harried nurses scurried about.
Finally his name was called, and he went to an office where a nurse conducted a presurgery interview. At first she seemed quite brusque—Schwartz felt like just another faceless patient. But when he told her he had lung cancer, her face softened. She took his hand and asked how he was doing.
Suddenly they left their nurse-patient roles, as Schwartz told her about his two-year-old son, Ben. She said her nephew was named Ben, too. By the end of their conversation, she was wiping tears from her eyes. Though she ordinarily did not go to the surgical floor in her job, she said she would come to visit him.
The next day, as he sat in a wheelchair waiting to be wheeled into the surgical suite, there she was. She took his hand and with teary eyes wished him luck.
That was but one of a series of compassionate encounters with medical staff, acts of kindness that, as Schwartz put it at the time, “made the unbearable bearable.”14
Shortly before his death, just months later, Schwartz created a legacy that he hoped would make such moments of benevolence more likely to reach many more patients. He founded the Kenneth B. Schwartz Center at the Massachusetts General Hospital, to “support and advance compassionate health care” that offers hope to patients and support to caregivers, and that aids the process of healing.15
The Schwartz Center bestows an annual Compassionate Caregiver Award to honor medical staff who have shown extraordinary kindness in caring for patients and so can serve as role models. Another promising innovation from the center is a variation of the standard medical grand rounds, which typically update medical staff on new developments in their fields. Instead, the “Schwartz Center Rounds” give hospital staff a chance to come together to share their concerns and fears. The premise is that from gaining insight into their own responses and feelings, caregivers will be better able to make a personal connection with their patients.16
“When we had our first Schwartz Center Round,” reports Dr. Beth Lown of Mount Auburn Hospital in Cambridge, Massachusetts, “we expected no more than sixty or seventy people, which is a good turnout. But to our surprise, around 160 medical staff showed up. These rounds really speak to a need for us to talk honestly with one another about what it’s like to do our work.”
As an officer of the American Academy on Physician and Patient, Dr. Lown has a unique perspective: “The motive to connect with people that draws so many into medicine gets slowly supplanted by the hospital culture—a biomedical orientation, technology-driven, and geared to getting patients in and out as quickly as possible. The question is not whether empathy can be taught, but what are we doing that drives it out of medical students?”
That medical certification exams now include an evaluation of interpersonal adeptness testifies to the new importance being placed on doctors cultivating skills like relationship- and rapport-building. One focus is the medical interview, which an average physician conducts up to two hundred thousand times over the course of a career.17 This conversation is the best chance for a physician and patient to develop a good working alliance.
The ever-analytical medical mind has broken the patient interview into seven discrete parts, from opening the discussion through gathering and sharing information, to making plans for treatment. The interview guidelines emphasize not the medical dimensions—that’s taken for granted—but rather the human one.
Physicians are urged, for instance, to let a patient complete his first statement rather than commandeering the conversation from the first few seconds, and to elicit all of a patient’s concerns and questions. They need to make a personal connection and understand how the patient perceives the illness and treatment. In other words, they need to deploy empathy and build rapport.
Such skills, Dr. Lown says, “can be taught and learned, but they must be practiced and cultivated like any other clinical skill.” And doing so, she argues, not only makes physicians more efficient but means patients will adhere to treatment better and be more satisfied with their care.
Kenneth Schwartz, writing just a few months before he died, put it more directly: “Quiet acts of humanity have felt more healing than the high-dose radiation and chemotherapy that hold the hope of cure. While I do not believe that hope and comfort alone can overcome cancer, it certainly made a huge difference to me.”
PART SIX
SOCIAL CONSEQUENCE
19
The Sweet Spot for Achievement
You are driving to work, planning an important meeting with a colleague, and intermittently reminding yourself that you must remember to turn left at the traffic light, not right as usual, so you can drop your suit at the cleaners.
Suddenly an ambulance screams up behind you, and you speed up to get out of the way. You feel your heart quicken.
You try to resume planning the morning’s meeting, but your thoughts are disorganized now and you lose concentration, distracted.
When you get to work, you berate yourself because you forgot to go to the cleaners.
This scenario comes not from some business primer but from the academic journal Science, as the beginning of an article called “The Biology of Being Frazzled.”1 The article summarizes the effects on thinking and performance caused by being mildly upset—frazzled from the hassles of daily life.
“Frazzle” is a neural state in which emotional upsurges hamper the workings of the executive center. While we are frazzled, we cannot concentrate or think clearly. That neural truth has direct implications for achieving the optimal emotional atmosphere both in the classroom and the office.
From the vantage point of the brain, doing well in school and at work involves one and the same state, the brain’s sweet spot for performance. The biology of anxiety casts us out of that zone for excellence.
“Banish fear” was a slogan of the late quality-control guru W. Edwards Deming. He saw that fear froze a workplace: workers were reluctant to speak up, to share new ideas, or to coordinate well, let alone to improve the quality of their output. The same slogan applies to the classroom—fear frazzles the mind, disrupting learning.
The basic neurobiology of frazzle reflects the body’s default plan for emergency. When we are under stress, the HPA axis roars into action, preparing the body for crisis. Among other biological maneuvers, the amygdala commandeers the prefrontal cortex, the brain’s executive center. This shift in control to the low road favors automatic habits, as the amygdala draws on knee-jerk responses to save us. The thinking brain gets sidelined for the duration; the high road moves too slowly.2
As our brain hands decision-making over to the low road, we lose our ability to think at our best. The more intense the pressure, the more our performance and thinking will suffer.3 The ascendant amygdala handicaps our abilities for learning, for holding information in working memory, for reacting flexibly and creatively, for focusing attention at will, and for planning and organizing effectively. We plunge into what neuroscientists call “cognitive dysfunction.”4
“The worst period I ever went through at work,” a friend confides, “was when the company was restructuring and people were being ‘disappeared’ daily, followed by lying memos that they were leaving ‘for personal reasons.’ No one could focus while that fear was in the air. No real work got done.”
Small wonder. The greater the anxiety we feel, the more impaired is the brain’s cognitive efficiency. In this zone of mental misery, distracting thoughts hijack our attention and squeeze our cognitive resources. Because high anxiety shrinks the space available to our attention, it undermines our very capacity to take in new information, let alone generate fresh ideas. Near-panic is the enemy of learning and creativity.
The neural highway for dysphoria runs from the amygdala to the right side of the prefrontal cortex. As this circuitry activates, our thoughts fixate on what has triggered the distress. And as we become preoccupied by, say, worry or resentment, our mental agility sputters. Likewise, when we are sad activity levels in the prefrontal cortex drop and we generate fewer thoughts.5 Extremes of anxiety and anger on the one hand, and sadness on the other, push brain activity beyond its zones for effectiveness.
Boredom fogs the brain with its own brand of inefficiency. As minds wander, they lose focus; motivation vanishes. In any meeting that has gone on too long (as most do), the vacant eyes of those trapped at the table will betray this inner absence. And we all remember days of ennui as students, absently staring out the window.
AN OPTIMAL STATE
A high school class is playing a game with crossword puzzles, working in pairs. Both partners have the same puzzle, but one’s copy has words filled in where the other’s has blanks. The challenge: help your partner guess the missing words by giving her clues. And since this is a Spanish class, those clues must be in Spanish, as are the words to be guessed.
The students get so swept up in the game that they are completely oblivious to the bell ringing at the end of class. No one gets up to leave—they all want to keep working on the puzzles. Not incidentally, the next day when they write essays in Spanish using the words they learned in the puzzles, the students show excellent comprehension of their new vocabulary. These students were having fun learning, yet they mastered their lessons well. Indeed, such moments of total absorption and pleasure may mark learning at its best.
Contrast that Spanish lesson with an English class. The topic that day was how to use commas. One student, bored and distracted, slipped her hand into her bag and discreetly pulled out a catalog for a clothing store. It was as though she had left one store in a mall for another.
Sam Intrator, an educator, spent a year observing high school classrooms like these.6 Whenever he witnessed an absorbing moment like the one with the crossword puzzle in the Spanish class, he would canvass the students on what they had been thinking and feeling.
If most students reported a state of total involvement in what was being taught, he would rate the moment “inspired.” The inspired moments of learning shared the same active ingredients: a potent combination of full attention, enthusiastic interest, and positive emotional intensity. The joy in learning comes during these moments.
Such joyous moments, says University of Southern California neuroscientist Antonio Damasio, signify “optimal physiological coordination and smooth running of the operations of life.” Damasio, one of the world’s leading neuroscientists, has long been a pioneer in linking findings in brain science to human experience. Damasio argues that more than merely letting us survive the daily grind, joyous states allow us to flourish, to live well, and to feel well-being.
Such upbeat states, he notes, allow a “greater ease in the capacity to act,” a greater harmony in our functioning that enhances our power and freedom in whatever we do. The field of cognitive science, Damasio notes, in studying the neural networks that run mental operations, finds similar conditions and dubs them “maximal harmonious states.”
When the mind runs with such internal harmony, ease, efficiency, rapidity, and power are at a maximum. We experience such moments with a quiet thrill. Imaging studies show that while people are in such exhilarating, upbeat states, the area of the brain that displays most activity is in the prefrontal cortex, the hub of the high road.
Heightened prefrontal activity enhances mental abilities like creative thinking, cognitive flexibility, and the processing of information.7 Even physicians, those paragons of rationality, think more clearly when they are in good moods. Radiologists (who read X-rays to help other physicians make their diagnoses) work with greater speed and accuracy after getting a small mood-boosting gift—and their diagnostic notes include more helpful suggestions for further treatment, as well as more offers to do further consultation.8
AN UPSIDE-DOWN U
Plotting the relationship between mental adeptness (and performance generally) and the spectrum of moods creates what looks like an upside-down U with its legs spread out a bit. Joy, cognitive efficiency, and outstanding performance occur at the peak of the inverted U. Along the downside of one leg lies boredom, along the other anxiety. The more apathy or angst we feel, the worse we do, whether on a term paper or an office memo.9
We are lifted out of the daze of boredom as a challenge piques our interest, our motivation increases, and attention focuses. The height of cognitive performance occurs where motivation and focus peak, at the intersection of a task’s difficulty and our ability to match its demand. At a tipping point just past this peak of cognitive efficiency, challenges begin to exceed ability, and so the downside of the inverted U begins.
We taste panic as we realize, say, we’ve procrastinated disastrously long on that paper or memo. From there our increasing anxiety erodes our cognitive efficiency.10 As tasks multiply in difficulty and challenge melts into overwhelm, the low road becomes increasingly active. The high road frazzles as the challenges engulf our abilities, and the brain hands the reins to the low road. This neural shift of control from the h
igh to the low road accounts for the shape of the upside-down U.11
An upside-down U graphs the relationship between levels of stress and mental performance such as learning or decision-making. Stress varies with challenge; at the low end, too little breeds disinterest and boredom, while as challenge increases it boosts interest, attention, and motivation—which at their optimal level produce maximum cognitive efficiency and achievement. As challenges continue to rise beyond our skill to handle them, stress intensifies; at its extreme, our performance and learning collapse.
The inverted U reflects the impact of two different neural systems on learning and performance. Both build as enhanced attention and motivation increase the activity of the glucocorticoid system; healthy levels of cortisol energize us for engagement.12 Positive moods elicit the mild-to-moderate range of cortisol associated with better learning.
But if stress continues to climb after that optimal point where people learn and perform at their best, a second neural system kicks in to secrete norepinephrine at the high levels found when we feel outright fear.13 From this point—the start of that downward slope toward panic—the more stress escalates, the worse our mental efficiency and performance become.
During high anxiety the brain secretes high levels of cortisol plus norepinephrine that interfere with the smooth operation of neural mechanisms for learning and memory. When these stress hormones reach a critical level, they enhance amygdala function but debilitate the prefrontal areas, which lose their ability to contain amygdala-driven impulses.
Social Intelligence: The New Science of Human Relationships Page 31
