This summer, the University of California, San Diego (UCSD), School of Medicine received a massive $100 million donation. The gift wasn’t for cancer research. It wasn’t for HIV/AIDS, Alzheimer’s disease, stroke, or the opioid epidemic. It was to investigate — and increase — compassion.
The donation came from T. Denny Sanford, a philanthropist whose interest in the study of compassion was fanned by a supportive message from the Dalai Lama. The Institute for Empathy and Compassion named in Sanford’s honor plans to merge the somewhat ethereal realm of lovingkindness with the empirical rigor of neuroscientific inquiry.
“My mom used to say it’s nice to be nice. Sure, that’s true,” says William Mobley, MD, the UCSD medical school neuroscience professor who is heading the institute. “It’s another thing to say there’s scientific evidence showing that compassion is good — and not just for others, but for you too.”
Moreover, interest in the neurobiology of compassion has exploded in recent years, notes Mobley, thanks in part to progress using magnetic resonance imaging and other high-tech tools. “We’ve got to understand the brain to understand the mind,” he says.
“My mom used to say it’s nice to be nice. Sure, that’s true…. It’s another thing to say there’s scientific evidence showing that compassion is good — and not just for others, but for you too.”
William Mobley, MD, University of California, San Diego, School of Medicine
So far, among other advances, researchers know where the brain lights up when a person donates to charity, looks at suffering, or thinks compassionate thoughts. And then there’s the accumulating evidence that, much like a muscle, compassion can be boosted with targeted training. “There’s a growing body of science that certain meditation practices can change the function and structure of the brain,” says Jon B. Klein, MD, PhD, vice dean for research at the University of Louisville School of Medicine.
But some researchers and educators don’t just hope to understand the neural intricacies of compassion. They want to apply what science says to boost the emotion among future physicians.
Increasing compassion in medicine certainly is a worthwhile pursuit. Compassionate care is associated with improved outcomes and greater patient adherence. And among providers, extending kindness is associated with reduced burnout and greater well-being. That’s particularly noteworthy because the stress of medical school and residency often chips away at empathy, while trainees also experience disturbingly high rates of suicide and depression.
Already, dozens of medical schools have begun to see the value of adding compassion training to curricula, whether as electives or required content.
“Compassion should be a skill we teach in medical school just like we teach how to do a physical exam,” says Klein. “It allows trainees essential insight into the suffering of their patients, and it boosts their own emotional resilience.”
The science of compassion
Ask people to describe their experiences extending kindness and they may not remember or report accurately. But objective measures captured in real time — nerve impulses, skin conductivity, and heart-rate variability, for example — can remove much of that squishiness.
Several studies using fMRIs have captured neural indicators of compassion. “When a person is thinking compassionate thoughts, we see increased activity in specific areas of the brain. The areas we see light up are the ones that are associated with reward or pleasure,” explains James R. Doty, MD, a Stanford University School of Medicine neurosurgery professor and director of the Center for Compassion and Altruism Research and Education.
What’s more, neuroimaging can even detect the difference between compassion and its cousin empathy.
“From a neuroscientific perspective, empathy differs from compassion. Empathy is experiencing the pain of others, which can be really toxic,” explains Richard J. Davidson, PhD, a professor of psychology and psychiatry at the University of Wisconsin—Madison and a pioneer in compassion research.
Davidson points to a study in which subjects were shown videos that sometimes depicted people experiencing pain. The researchers also occasionally sent slightly painful bursts of heat to subjects’ hands. The results were telling: Viewing images of pain and experiencing it personally triggered the exact same brain response.
“When a person is thinking compassionate thoughts, we see increased activity in specific areas of the brain. The areas we see light up are the ones that are associated with reward or pleasure.”
James R. Doty, MD, Stanford University School of Medicine
Compassion, on the other hand, involves the more uplifting emotion of wanting to address someone else’s pain. “We need to transform empathy to compassion,” says Davidson. “People talk about compassion fatigue. That’s an unfortunate misnomer. If you’re really experiencing compassion, it’s not fatiguing, it’s nourishing.”
How to move from empathy to compassion is among the many questions researchers still hope to answer. So are what drains compassion and precisely how related neural circuits interact. Also high on their list is identifying which trainings will best expand future physicians’ inherent compassion for patients — and for themselves.
Boosting the compassion muscle
Compassion trainings vary, but all involve a contemplative focus on kindness.
Klein describes one version he used: “You start by visualizing someone you love, and you imagine a time they suffered — maybe they were ill or injured,” he explains. “Then you visualize relieving their distress. How does it make them feel? How does it make you feel? Next you gradually extend that compassion to a friend, a neutral person, and, finally to someone disagreeable,” he adds. “You’re increasing your barriers to compassion with each stage of training, like you would work a muscle harder over time.”
In one major study led by Davidson and colleagues, subjects engaged in a similar compassion exercise for 30 minutes each day for two weeks. The result? Their fMRI scans captured significantly more activity in compassion-related brain areas when they looked at images of suffering compared to controls.
But that was hardly enough to satisfy for Helen Weng, PhD, one of the researchers involved. “I don’t really care if you generate positive emotions towards people if it doesn’t affect your life off the meditation cushion,” says Weng, a University of California, San Francisco (UCSF) assistant professor of psychiatry and faculty member at UCSF School of Medicine’s Osher Center for Integrative Medicine. “I care about what’s going to change people’s behavior and result in more kindness.”
So the same study also compared the impact of compassion training to training in how to decrease negative feelings. In an online activity, the compassion trainees were more willing than controls to donate money to someone who had suffered an economic injustice. “The people who practiced the compassion meditation spent almost twice as much money righting the wrong,” Weng says, “and the more activity in the brain regions, the more they gave.”
“Environments that cause stress diminish our capacity for compassion…. We sometimes forget that even the smallest act of kindness to another can have a profound effect on them.”
James R. Doty, MD, Stanford University School of Medicine
For her next experiment, Weng decided to examine people’s willingness to focus — literally — on suffering. She used eye-tracking technology to monitor how long people looked straight at suffering in an image versus how much they averted their eyes. “The people who did the compassion training and could look more at the suffering also had decreased activity in the amygdala, which is involved in stress,” Weng reports. “This suggests that they were able to remain calm in the face of suffering.”
Remaining calm in such moments is particularly important in medicine, Doty notes. “Environments that cause stress diminish our capacity for compassion,” he says. “When the amygdala is activated, we have a decrease in pathways associated with nurturing. We take shortcuts because we’re in survival mode…. We sometimes forget that even the smallest act of kindness to another can have a profound effect on them.”
More compassionate medical students
When Klein proposed teaching a medical school course on compassion, his supervisor “did a bit of eye rolling,” he recalls. But the eight-week course that launched in 2012 — a blend of psychology, neuroscience, and Tibetan meditation, Klein says — has paid off. Students experience around a 10% to 15% increase in compassion-related skills such as accepting without judgment, Klein says, and a 2019 publication reported that students often applied these skills to personal, academic, and clinical situations.
Victoria Elliott, MD, still uses what she learned three years later. “When things get challenging, it helps me re-center and focus on why I went into medicine in the first place. I use compassion and try to think of what patients are experiencing,” says Elliott, now a third-year resident at Johns Hopkins All Children’s Hospital in Florida. “I’d say my work seems more enjoyable and easier than for my colleagues who haven’t had compassion training.”
“There’s a very contentious argument between people who think these programs help and others who say, ‘Don’t teach me to meditate. Fix the EMR, fix the problems that cause stress.’”
Jon B. Klein, MD, PhD, University of Louisville School of Medicine
Doty highlights one key element of many compassion trainings: kindness toward oneself. “One of the challenges for medical students, or anyone in training, is thinking we’re not smart enough or talented enough. We go into self-rumination. ‘I’m never going to be a doctor. I’m a failure,’” he says. “Self-compassion lets you recognize that you’re okay as you are. You can step out of your own suffering, which frees you up to focus on the suffering of others.”
Despite their growing popularity, such trainings aren’t without controversy. “There’s a very contentious argument between people who think these programs help and others who say, ‘Don’t teach me to meditate. Fix the EMR, fix the problems that cause stress,’” says Klein.
“I think they are both right,” he adds. “I don’t think people will be equipped to create the systemic changes in medical education and practice we badly need unless they’re more self-aware and compassionate.”