Do doctors need to be kind?

Kind doctors.

I don’t think I am a kind person. Compared with my peers I am a fast cyclist, an articulate debater and a reasonable baker of bread. But neither I, nor I suspect my peers, would rate kindness amongst my defining characteristics.

This is not to say that I am unkind or cruel, either in my own mind or in the minds of those who know me. Since I once shot and ate a grey squirrel, in the eyes of some I am irredeemably cruel, but on the whole my dealings with the natural world are concerned with wellbeing and sustainability. According to a wonderful new book which has inspired this post, Intelligent Kindness, Kindness is something that is generated by an intellectual and emotional understanding that self-interest and the interests of others are bound together and acting upon that understanding. (p5) Perhaps I should have paid more attention to the squirrel’s interests.

In matters of kindness and my medical practice I identify with John Launer, who confessed that as a doctor, “I could certainly remember significant acts of kindness that I felt proud of, but I could also recall an equal number of occasions—if not more—when I performed my tasks in a spirit of irritable efficiency, doing what was right because I knew this intellectually rather than through genuine warmth”

Kindness in healthcare is how we communicate with and relate to our patients, our colleagues and ourselves. It is much more than how we listen, it is how we feel and how we respond and it is part of the culture we share.

John came in to see me clutching a long list of medications from his recent hospital stay and latest surgery to remove another portion of severely ulcerated bowel. He looked tired and pale. We talked about how he was managing and he joked, “you mean apart from the surgery, the bloody stools, the leaking colostomy, the painful wound that refuses to heal and the exhaustion and insomnia? Fine! no really … there comes, or rather came a point when I stopped thinking about my body and started looking down at that thing … my stomach … as something I have to carry around, that needs to be booked in for repair from time to time with Miss Flood [the surgeon] who knows it more intimately by now than I do, that has its own set of emotions, mostly festering with angry outbursts these days … ” he tailed off. “How are things at home, how do you think you’re coping now?” I asked. “Really doc, they’re fine, everyone’s been chipping in and helping out” I couldn’t help thinking from the way he said it that everything wasn’t fine, but after a few more minutes I realised he didn’t want to talk about it.

I invited him onto the examination couch to examine his abdomen and look at the results of his most recent operation. I pulled the curtains around and washed my hands as he took off his jacket and shirt, loosened his trousers and sat on the edge of the couch. I put my left hand on his shoulder and looked at him as he stared at his bulging colostomy bag, the dressings and the scars. A habit ingrained since student days of examining patients hands at the beginning of any formal clinical examination led me subconsciously to take his hand as he lay down and inspect his palm and nails before placing one hand carefully on his abdomen. I saw the first tear well up in the corner of his right eye. As I moved my hand gently over the battlefield scars he began to talk again. “You know Angela’s left me? no … of course you don’t … or maybe she told you … I know you’re her doctor too. She couldn’t cope any more, not knowing if I was going to die from my Crohn’s or kill myself because of depression … ” I paused, my right hand still resting on his stomach, he was staring at the ceiling with the tears making damp patches on the couch. I helped him sit up and he dressed in silence while I washed my hands again. When we sat down again, he talked openly about how impossible it had been for Angela to cope with him, how he had stopped taking his medication, had cut himself and tried to kill himself in a drunken rage, hating this thing that his body had become. Conversations like this pay no heed to the 10 minute parcels of alloted general practice appointment time. We could have ended at precisely 11 minutes before the examination, but we knew there was more. Only the ritual of undressing and laying on of hands, in some ways like the biblical washing of feet, allowed John to open up.

But I don’t know even now if ‘kindness’ was my motivation or even if what I did was ‘kind’. I think it was gentle and professional, but I’m not sure how to define kindness, and yet I have no difficulty thinking of kind people. I feel humbled in their company and I wish I had more of their kindness. I think we all know what we mean when we say that someone is kind even if we cannot put kindness itself into words.

We want kindness to be genuine, not contrived in order to coax out a clinical history. Perhaps because of kindness’ association with love we only want to receive it if it is true and we don’t want to be deceived.

There are good reasons for understanding kindness to be a natural predisposition, part of what counts in being human. The word ‘kind’ has the same etymological roots as ‘kin’, ‘kindred’ (family) and ‘kind’ (‘type’). This is suggestive of a natural relationship of kindness between members of the same family, group or species. The Shorter Oxford English Dictionary (gives the first definition of ‘kindly’ as ‘existing or occurring according to the laws of nature’, thus implying that kindness is natural capacity. Stoic philosophy celebrated the natural order as a basis of its ethics. Thus the Roman Emperor Marcus Aurelius, a leading Stoic philosopher, speaks of kindness as ‘mankind’s sic] greatest delight’ Kindness in pedagogical practice and academic life Bit. J. Sociology & Education

Kindness alone is not enough. It must be combined with skilled and attentive listening and competent clinical skills. But this is surely obvious, and whilst there may be a tension, one would hardly wish for a kindly but clinically incompetent doctor.

The myths we live by.

There are those who believe that given a choice between kindness and competence or either a doctor who is kind or one who is a good listener, kindness would take second place. But in most situations this is a rhetorical fallacy, a false dilemma, we should not have to choose. In practice very often kindness, competence and listening skills are inseparable. Dr Sassall in Berger’s A Fortunate Man, is as exacting about applying scientific evidence (before evidence-based medicine was a twinkle in the eye of its inventors) as he is committed to the fraternal bond that develops over years with his patients. This bond includes sitting with them and their families at the threshold of death.

I think that people who imagine that they would prefer, like the founder of the NHS Aneurin Bevan, to “be kept alive in the efficient if cold altruism of a large hospital than expire in a gush of warm sympathy in a small one” are imagining their experience of illness to conform to one of the stories we tell about illness and medicine; that of the healthy victim who is struck by malevolent illness, diagnosed by the heroic doctor, saved with medical science and restored back to good health. In TV dramas, epitomised by House MD, diagnosis is everything. The patient, frequently barely conscious, life slipping away, depends on the heroic doctor making the diagnosis before the clock runs out. This is one of the myths we live by, the ‘restitution narrative’. It is the dominant narrative of our time. It is the story we tell about modern medicine and the story that we doctors like to tell about ourselves. But this is only one of several different narratives we could tell, especially given the predicted 250% increase in people suffering from long-term conditions over the next 40 years. The restitution narrative is appropriate after trauma or when we need emergency treatment for our meningitis, but for many people the reality of illness is one in which the doctor is not a hero, like Dr House who moves on after saving the patient’s life, but someone who makes a committment to their patients and joins them in a partnership, managing and negotiating, helping them to learn about and cope with illness or disease that cannot be cured; like heart or lung disease, diabetes or cancer, depression or addiction. The patient is not the restitution narrative’s brief, passive recipient of care, but fully conscious, involved practically and emotionally for the long haul.

Competence without kindness is not without risks,

Henry, like quite a few of my patients, smoked a lot of crack in the ’90s. Like most people who have smoked a lot of crack, he hasn’t experienced much kindness. From early childhood he experienced abuse and mistrust, and by and large he gave as good as he got. Consequently when he eventually presented to his GP with a sore throat some time in the noughties, it took a long time for someone to have the kindness to see that behind the argumentative drug-addict was a person with a serious symptom. Now, fortunately he is alive, though his cancerous voice box has been removed and in order to speak he has to put a finger on the valve over the hole in his neck.

Another consequence of competence without kindness is that we take physical symptoms at face value without exploring their meaning or psychological impact. In the case of angina, a type of chest pain bought on by ischaemic heart disease, clinical competence and enthusiasm combined with perverse financial incentives have been responsible for enormous over use of invasive procedures. In contrast, cardiologist Bernard Lown significantly reduced the numbers of procedures performed on his patients. Reflecting on how he did this, he writes, “We encouraged optimism. We addressed social and family problems. We discussed significant psychosocial stresses. We minimized shuttling patients to other specialists. Foremost, doctors spent much time listening, thereby fostering trust and adherence to prescribed lifestyle changes. We did much for the patient and as little as possible to the patient” Essay 29

Nevertheless, the chief tension is not between kindness and clinical competence, but between a model of care based on meaningful relationships and one based on short-term contracts and health care consumerism.

In common with Intelligent Kindness, Annemarrie Mol’s book, The Logic of Care and the Problem of Patient Choice, shines a light deep into the well of problems the marketisation of healthcare presents. Patients are being converted into consumers, each representing potential profit or loss, conflicting with the person in need of care.

Three lessons for teaching kindness.

Kindness is, or ought to be like background radiation, ever-present in our lives. The main and most effective way we learn about kindness is to experience the kindness of others. It seems obvious, after all children who are treated with affection are more likely to grow up to be kind than those whose parents are emotionally neglectful or abusive. It is not enough for kindness to be taught as a clinical skill, to be used in the taking of a medical history, the personal care of an elderly patient or in counselling. We need institutions and cultures where people are kind to each other, where kindness is valued and nurtured in everything we do. Unless we are routinely subject to the kindness of others we will have little kindness to share ourselves. The kindness of others sustains our own.

Doctors and other health professionals frequently complain that their stores have run dry at the end of a long day and that they have little kindness left for those they are supposed to love. Depression, alcoholism, drug abuse and suicide are common in doctors and have been linked to self-criticism, perfectionism, isolation and poor support (DH) Not only must we have kindness left for our families, but for ourselves.

The second lesson about kindness is that it grows with familiarity: we care more about people who are close to us. Because of this, continuity of care needs to be valued and built into healthcare systems. Whenever patients with long-term conditions re-attend for care it matters that they know the professional they are meeting, most crucially of all when they are mentally ill or dying. It can also matter in an emergency. Three weeks ago footballer Fabrice Muamba suffered a cardiac arrest in the middle of a match, “Seventy-eight minutes is a long time to try and revive anyone,” [his fiancee] Shauna recalls. “It was only the personal connection between Dr [Jonathan] Tobin [the Bolton doctor] and Fabrice that kept them going. Dr Tobin told me that. Obviously, when you have a personal relationship, if it’s your child or wife, then you’re going to pump a bit longer. They thought about stopping twice. Dr Tobin said, ‘No, let’s try again,'” And they kept on trying until they saved his life. Times interview 05/05.12

The third lesson, closely related to continuity, is that kindness is related to holistic or ‘whole person’ care. We care more when we are involed with the care of person than an organ. The increasing industrialisation and specialisation of care is undermining both continuity and holism, as one specialist attends to the heart, one to the lungs, one to the kidneys and so on. In nursing, different grades come and go, one for washing, one for feeding, another for dressings and another for drugs, and yet another to explain what is going on. When the patient breaks down in tears the on-call psychiatrist (or psychiatric nurse) is called. This is what psychotherapist, Michael Balint referred to as the ‘collusion of anonymity’ in which ultimately no-one takes responsibility for the person, because each professional is only responsible for their organ of specialist interest. As GPs develop their own special interests and devolve responsibility to a wide array of auxiliary grades, we too collude in this neglect of the whole patient. Driving wedges between professionals and patients is a processes of commodification and industrialisation in which both the patient and those caring for them are broken down into their constituent parts and roles for the sake of economics (each part can be assigned a tariff) and efficiency (the simplest roles are given to cheaper staff). The tension is not between kindness and competence, but between kindness and capitalism, ‘attending to [kindness] can be subversive of neo-liberal assumptions that place value on utility and cost above other human values.’ One way of institutionalising kindness is to de-institutionalise market values.

I don’t believe that there was a golden age of kindness in the NHS, mostly because it was never acknowledged as an important part of the culture of care. At the recent enquiry into the patient deaths at North Staffordshire hospital witnesses repeatedly told of a bullying culture within the wider NHS and that the Department of Health continued to focus on issues of finance and not quality (Guardian) The recent Health and Social Care bill accelerates a trajectory of transformation from public service to competitive private business in which efficiency savings and productivity gains are the predominant values.

Iona Heath, in her review of Intelligent Kindness for the British Medical Journal writes,

… “it is easy to forget the appalling nature of some of the jobs carried out by NHS staff day in, day out—the damage, the pain, the mess they encounter, the sheer stench of diseased human flesh and its waste products.” Of course, such forgetfulness is not at all easy for those actually doing this work, those struggling not to allow any hint of their physical revulsion to show, but these challenges seem hardly to register in the conscience or consciousness of those charged with the running of the NHS.

The NHS represents the last vestige of social inclusiveness and solidarity for frail, elderly people; for traumatised children; for people with intellectual disability, dementia, or severe mental health problems; and for people who repeatedly harm themselves, either directly, or persistently through the misuse of drugs and alcohol. And yet the staff who do the hard work of maintaining that solidarity are subject to a constant stream of criticism, efficiency savings, and instructions to do better. Exposed to precious little kindness themselves, they are nonetheless expected to provide it unstintingly. “There is a lack of understanding, a lack of thoughtful connection—a lack of kindness in the way the organisation as a whole is treated.”

What patients want.

What patients say they really want from doctors is someone who is kind, offers hope and certainty, provides relief from suffering, and is available at short notice. This is in contrast to the system of care we are developing which is increasingly concerned with procedures and efficiency, aims to be honest about risks and uncertainty, treats healthy people to prevent future complications, and aims to manage demand with triage and self-care.

What can be done?

First of all we need to start talking about kindness. We need to talk about the value of kindness in healthcare and agree that it has been neglected and that we need to take action. Everyone involved in health leadership and policy should read Intelligent Kindness, in summing up her review of Iona Heath wrote, “If I ruled the world, I would arrange for everyone who wields any power in the NHS to be locked in a room until they had read it.”

Once we have agreed that it is important we need to do something to institutionalise kindness. We must focus on patients by improving continuity and a holistic approach to care. In order to be kind to patients, we must cultivate kindness between and towards ourselves. John Launer described an experiment at Indiana Medical school in which researchers recorded the positive narratives of students and staff, focusing on postive experiences and not the failures and critical incidents they were used to. They were then presented with the findings, “One participant is quoted as saying afterwards: “Now that I see how good we really are, I have to ask myself why we tolerate it when people aren’t as good as this. I can’t look on quietly any more when people are disrespectful or hurtful. It’s no longer okay to remain silent; this is too important.” Kindness improved quality of clinical care and was contageous, spreading and tranforming the organisation.

The relentless focus on efficiency and productivity in healthcare highlights the intrusion of market values into the NHS. There is an urgent need to to defend the values of social solidarity and rediscover an intellectual and emotional understanding that self-interest and the interests of others are bound together and acting upon that understanding. By committing ourselves to the values of kindness we may yet rescue the NHS.

Intelligent Kindness: Reforming the Culture of Healthcare. John Ballatt & Penelope Campling. RCPsych Publications.

Kindness in Healthcare, What goes around. Iona Heath review of Intelligent Kindness BMJ

Kindness and healthcare:

Threats cannot make healthcare workers more compassionate. Paul Gilbert. Guardian

Is the quest to build a kinder, gentler surgeon misguided? July 2014

The Kindness of Strangers Palmer BMJ

Balancing act, Teaching kindness AAFP

Kindness, Prescribed & natural in medicine AAFP

A doctor’s touch Abraham Verghese: Tedx talk

The Human Touch. Lovely blog by Dr Laura Jane Smith. Respiratory physician.

After Mid Staffs the NHS must do more to care for its staff. BMJ “I found that healthcare workers were some 70% more likely to have developed work related stress, depression, or anxiety than was the general workforce” “NHS management seemed not to understand that it had a duty to protect its staff from the pressures under which they were working. This was a callous disregard for staff wellbeing.” “… the 2012 prevalence of work related mental health problems in health professionals was 110% higher than in the general workforce”

Compassion is what’s common in the NHS, not cruelty Lisa Rodrigues NHS Voices Blog

Compassion Champions needed to tackle NHS empathy deficit. The Conversation

Teaching kindness:

On Kindness J Launer BMJ post grad. med. J.

Compassionate Care, the theory and reality. Alys Cole King and Paul Gilbert.

Kindness in pedagogical practice and academic life Brit J. Sociology & Education

The Paradox of Teaching Empathy in Medical Education. Shapiro. Googlebook

Real compassion demands much of us. It requires sincerity. Compassion that is not genuine is illusory and fragile. Compassion depends on us being willing to take risks with our own emotions and professional identities. It is hard work. Everybody’s and nobody’s responsibility. Deborah Bowman.

Listening to patients:

Just listening, narrative and deep illness Asking the right questions about pain The Wounded Storyteller. Frank, Arthur.

Telling the story: http://www.aissg.org/articles/TELLING.HTM

The art of listening to the elderly patient. Bernard Lown

Shared mind, communication, decision making and autonomy in serious illness

I’m sorry to have to tell you this. Empathy and doctors: Wishful thinking in medical education

Cold comfort. Essay about a doctor’s experience of too little kindness as a patient

Depression and doctors:

Mental Health and ill health in doctors. Dept Health

Doctors support network

When Doctors get depressed. NY Times.

Too much kindness:

A Fortunate Man. John Berger.

Beware of pity. Stefan Zweig.

Markets values and kindness.

Maslow’s hierachy of needs

Mol, AnneMarie: The Logic of Care and the Problem of Patient Choice.

What do patients want from health care?

Courteous but not curious: how doctors’ politeness masks their existential neglect. A qualitative study of video-recorded patient consultations

The Myths We Live By. Mary Midgley

What isn’t for sale? Michael Sandel

The Importance of kindness at work Harvard Business Review August 2013

George Saunders’s Advice to Graduates NY Times August 2013