- Dr John Launer, London Department of Postgraduate Medical Education, Stewart House, 32 Russell Square, London WC1B 5DN, UK;
“I’m not a clever doctor, but I am a kind one.” My colleague’s statement was striking and I have remembered it for many years. He was another local general practitioner (GP), close to retirement, and I was interviewing him as part of a research project. Everything I had learned about him during the conversation supported what he said. He wasn’t a high earner by comparison with most GPs, mainly because he cared little for ticking the boxes on lucrative but clinically pointless targets set by the local primary care trust. However, his surgery walls were covered with framed photos of weddings and new babies from among the local families he cared for, and his window sill was hidden underneath dozens of thank you cards. I discovered that he was now looking forward to retirement because it would allow him to be a full time grandparent to his daughter’s little boy and girl whom he adored. At the same time, he was worried that his former patients might fall into the hands of a younger GP of the sort who might install a large, visible clock in the consulting room, or who might think it improper to take someone’s hand in sympathy.
When the interview had finished he escorted me out through the waiting room. His evening surgery was about to start. He greeted each of the patients with a friendly smile or a touch on the shoulder. I sensed no element of sentimentality or theatre in this. It was the quality he had himself identified as his main strength: kindness. I wondered how many more doctors like him I would ever meet before the numbing effects of bureaucracy and defensive medicine became universal and made this way of practising unknown. I also wondered how many of us would ever look back on our careers as doctors and make a similar judgement of ourselves. In my own case, 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. Perhaps this barely mattered for much of the time: the prescription I wrote might have achieved the same result anyway. But I have no doubt that there were many occasions when the missing ingredient was the crucial one, and patients failed to engage with my advice or to follow it through because it seemed disengaged and mechanical—or because they believed that soulless medicine couldn’t be trusted.
WISE DECISION MAKING
A recent “Personal view” in the BMJ makes this point even more forcefully.1 In a piece entitled “The kindness of strangers” the medical director of a hospice describes the death of her father, and then of her life partner and soul mate. She tells of how “an invisible, untaught web of kindness and generosity” was spun around each of these losses. In the rest of the article she offers her thoughts on the new national end of life strategy in England, and on measurable outcomes. She laments our overreliance on e-learning and competency frameworks, arguing that these are no substitute for wise decision making and kindness. She reflects on what outcomes might be truly meaningful. “I could think of only two,” she writes. “ ‘Did I hear what matters most for this person right now?’ and ‘Was I kind?’ ”.
As an educator, I was arrested by this article too. Much of my work centres around teaching communication skills. We pay a great deal of attention to attentiveness to language and sensitivity to emotion. But I cannot remember ever using the words “wisdom” and “kindness” in a seminar or lecture. Since reading the article, I have started to imagine what it would be like if we made these virtues transparent in our teaching rather than implicit, or if we were bold enough to point out that the best communication techniques in the world are empty without them. I have also been thinking about whether we should assess kindness as an important outcome of training. As well as observing whether students followed verbal feedback and body language, perhaps we could also ask “were they kind?”.
I am sure there would be risks in doing so. It might reward those with advanced skills as actors, rather than those with genuine compassion. Kindness could also wither under observation, through some kind of Heisenberg principle of the emotions. Yet we could certainly inquire about it after real professional encounters, where it would be harder to fake it. When seeking opinions from patients for appraisal purposes, as we often do nowadays, it might be possible to include the simple question: “How far were you treated with wisdom, and with kindness?”
At the same time, kindness is so often characteristic of an institution, or of a whole team or department, rather than of a single individual. It can be difficult for a doctor or nurse to behave humanely if the culture of the place is harsh to patients. In this regard, we can learn a useful lesson from an initiative that took place in Indiana University a few years ago, when a team of researchers and volunteers undertook the exercise of changing patterns of interaction across an entire medical school.2 Although they did not explicitly aim to produce kindness, this is exactly what they achieved.
Recognising that an exercise involving a whole organisation would defy a conventional linear design, they embarked on interviews with a large selection of students, residents, fellows, faculty and staff. They asked these people to identify narratives of positive experiences from their working lives, and recorded these systematically. By doing this, they hoped to capture peak moments at work, rather than dwelling on critical incidents and negative perceptions.
The most striking effect of the research was how much it brought out feelings of closeness, respect, joy and hope for interviewee and interviewer alike. When the team presented the narratives in public, the medical school community was reminded of “its deep reservoirs of caring about patients and students”. 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.” Another interesting finding was the linkage between the level of emotional care, and the outcome of care in the technical sense. One faculty member, for example, described how he was able to manage a complex surgical case because of the amount of trust and honesty that were present among the clinicians, and with the patient and his family.
ACTS OF CARE
Following the initiative, there seemed to be a ripple effect in the medical school, with small acts of care and kindness spreading across the institution. At a subsequent committee meeting one participant simply rearranged the furniture to enable people to sit closer together. Another person was moved at a finance meeting to give voice to feelings of heartbreak at budget cuts, even though there was no precedent for such personal comments. A senior faculty member was observed making a significant detour from his path to the hospital parking garage to escort a “lost-looking couple” to their destination. Complimentary remarks and emails became more common across the whole medical school.
The authors analyse these consequences in terms of a theory known as CRP, or complex responsive processes.3 According to this theory, small changes in behaviour can sometimes spread quickly and widely, transforming organisational patterns of thinking and interaction. The theory encourages those who want to change their workplaces to focus not on “elaborate idealised designs” but instead to participate positively in here-and-now interactional processes.
I find the research impressive, and the theory is persuasive. Yet it also makes sense simply at a human and intuitive level. I doubt if the GP whom I interviewed all those years ago would have needed any research, or any knowledge of CRP, to behave as he did, or to realise it would make a difference to his patients and to their health. Perhaps being clever and being kind are not so different after all.