Kindness in health care: missing in action?

~ Carolyn Thomas

by Carolyn Thomas  ♥  @HeartSisters 

I don’t remember much of what happened during that fateful visit to the Emergency Department.  I remember the on-call cardiologist saying something to me about my “significant heart disease”. After hearing those words, I felt so stunned that – although I could see his lips moving and could hear sounds coming out of his mouth – he may as well have been speaking Swahili.  (Doctors, please remember this in the future when delivering life-altering diagnoses to your patients!)

What I do vividly remember, however, is a small but profound act of kindness later that day when I was brought to my bed in the CCU (the cardiac intensive care unit). The nurse who came to greet me as my gurney was pushed off the elevator placed one gentle hand on my shoulder (and more importantly kept it right there as she walked alongside down the long corridor).  As we moved, she bent lower over my head to speak slowly and softly into one ear, introducing herself and assuring me that I was “in the right place” – and that her whole team would do their best to take very good care of me while I was with them.

Kindness is a kissing cousin to courtesy and respect.  I’ve written about modern medicine’s distressing lack of each, specifically when we encounter, for example, E.R. staff posting on Facebook about that day’s trauma patients, health care professionals talking over their patients as if they were invisible pieces of meat on a slab, or hospital staff not bothering to introduce themselves.

The concepts of courtesy and kindness from our health care providers is, in fact, far more important than many professionals realize.  In Dr. Iona Heath’s British Medical Journal review of the book called Intelligent Kindness, she wrote:

“Anyone who has been seriously ill knows that it is the individual acts of kindness, thoughtfulness, and sensitivity on the part of healthcare staff that make it possible to cope with the panic and indignity of a failing body.

“Kindness helps healing.”

U.K. physician and writer Dr. Jonathon Tomlinson certainly knows this, too. He believes that kindness is strongly linked to holistic or ‘whole person’ care – as he wrote in his powerful blog post Do Doctors Need To Be Kind? 

“We care more when we are involved with the care of a person, not just 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.”

He also cites psychotherapist Michael Balint, author of the classic 1957 text about the doctor-patient relationship, The Doctor, His Patient And The Illness:

“This is what he 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.”

I once wrote about similar research findings that found (surprise!) that medical care actually improves when physicians consider the whole person. For example:

“When doctors treat their patients like whole persons who have a full and complex life outside of the hospital or the doctors’ waiting room, things get better.

“When doctors actually listen to what their patients are telling them – and ask questions about what they aren’t – things get better.

“When doctors take the time to find out more about what Dr. Victor Montori and his Mayo Clinic-based team describe as the “burden of treatment” that’s particularly common in those patients living with one or more chronic diagnoses, things get better.”

Dr. Montori (author of the amazing little book called Why We Revolt) works on an innovative perspective toward what he calls “careful and kind care” in medicine called Minimally Disruptive Medicine. It’s like kindness in action.  This perspective encourages health care professionals to remember that a number of factors are actually at play for many patients who might appear at first blush to be simply non-compliant (arrrgh! that word again!)  As he explains in this essay on careful and kind care:

“Kind care requires us to the see the patient in their rich context, including their history, their aspirations, and their strengths and limitations in light of their struggles. In particular, it requires us to respect the scarce resources they must mobilize to access and use care and to enact self-care we recommend for them. We need to develop a deeper understanding of the work associated with being a patient, of the capacity available to shoulder that work, and how life affects both.

“Signs of kindness would be to not waste people’s time or effort and to stop describing them as being non-adherent or non-compliant.”

Managing this burden of treatment can feel like overwhelmingly hard work. Dr. Montori believes that caring about what’s really going on for such patients can have a profound overall effect:

“A patient’s education level, literacy, state of depression, pain, fatigue, social connectivity and supports, financial status – all of these affect a patient’s capacity to do the work.

“The workload can simply exceed capacity to cope.”

A 2008 New York study reported in The Annals of Family Medicine found that physician qualities like kindness were so important to the Latina women being studied that the absence of such qualities affected what medical information these women were even willing to share with their doctors.(1)

Much of this interaction, however, depends largely on health care professionals’ ability to empathize – to imagine what it’s like to walk in the hospital booties of their patients.

So it’s shocking for many people to learn that, even among naturally kind and empathetic medical students, studies suggest that empathy for others begins to wane by the third year of med school as students progress. This is particularly true, apparently, for future doctors entering technology-oriented specialties – like cardiology.(2)

Some people prefer the concept of responsiveness rather than empathy.  As psychiatrist, Harvard professor and author Dr. Robert Berezin describes this concept, responsiveness is a process of emotional receptivity in which “one is directly tuned into and involved with the other person with no reference to oneself at all.” 

That sounds like kindness to me.

Dr. Tomlinson adds that this response has little to do with being competent in providing expert physical care to patients.  But it’s also dangerous to believe it’s somehow acceptable for a graduating med student to have one trait (competence) without the other (kindness). As he says:

“A consequence of competence without kindness is that we take physical symptoms at face value without exploring their meaning or psychological impact.”

But it may not have always been like this in the practice of medicine, as cited in a must-read essay by pioneering cardiologist Dr. Bernard Lown who describes how he treated his own heart patients during his remarkable career:

“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.”

So in the end, what can be done to increase awareness of the importance of basic kindness in our health care?

Dr. Tomlinson argues that kindness grows with familiarity, and that we intuitively care more about people who are close to us. It’s why continuity of care needs to be valued and built into healthcare systems. This matters, he explains, especially for patients with longterm medical conditions, in that when they must keep coming back for appointments, they know the professional they are meeting. He advises his medical colleagues:

“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 BMJ review, Dr. Iona Heath wrote: ‘If I ruled the world, I would arrange for everyone who wields any power 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.

“And in order to be kind to patients, we must cultivate kindness between and towards ourselves.”

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(1) Kell Julliard et al. What Latina Patients Don’t Tell Their Doctors: A Qualitative Study. Ann Fam Med. 2008 November; 6(6): 543–549.

(2) Chen DC, Kirshenbaum DS, Yan J, Kirshenbaum E, Aseltine RH. “Characterizing changes in student empathy throughout medical school.” Medical Teacher. 2012; 34(4):305-11.

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Q:  Can you recall a particular kindness that affected your own health care?

NOTE FROM CAROLYN:  I wrote much more about common courtesy in health care in Chapter 1 of my book, “A Woman’s Guide to Living with Heart Disease”. You can ask for it at your local bookshop (my preference!) or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 20% off the list price).

See also:

News flash: care improves when doctors consider the whole person

The lost art of common courtesy in medicine

Six rules for navigating your next doctor’s appointment

Just not listening – or “narrative incompetence”?

Empathy 101: how to sound like you give a damn

Stupid things that doctors say to heart patients

Why aren’t more doctors like Dr. Bernard Lown?

Would it kill you to treat your patients with respect?

An open letter to all hospital staff

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Published by Carolyn Thomas

38 thoughts on “Kindness in health care: missing in action?”

  1. Pingback: Health as a Human Right

  2. I think smile is one of biggest kindness work in the world for any person. No, I have not remembered any act of kindness. But I like your blog it is very interesting to read.

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  4. It’s a sad, sad thing when we providers have to be reminded of this. If kindness and empathy are not front-and-center in what motivates any of us to become clinicians, then what the heck is?

    Sometimes I think that no one should be granted a license to become a clinician before we’ve been patients ourselves. I’ve always thought it was a great advantage to get my clinical degree in my late thirties — I got my license to be a physical therapist when I was forty! — because I knew what it was like by then to be a patient. When someone asks me what’s the most important part of what I do in my job, I usually say that it’s to try to be kind. Great post. Will be sharing this one. Kathi

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  5. When I was staying at the cardiac unit, I thought about the same. Kindness is so important for some people who are seriously ill. And sure if it does not heal, it can help with patient’s fears — you know, it is really scary to experience a heart attack. When you have no idea what’s going on and what’s your future at all.

    Mostly, I have experienced ignorant and rude attitudes at the hospital. Except one episode. I fell asleep one day for some minutes, and when I woke up, I saw a young man standing beside my hospital bed looking at me and smiling. “You were asleep so sweet and sound. I did not want to wake you up..” he said. It was my cardiologist’s fellow assistant. His name is Doctor Herz which means “heart” in German…

    I have never seen this guy afterwards. But he was the only person who did not kick me out and listened to me when I came to my cardiologist’s office with heart attack symptoms. Luckily, he was on his shift instead of the head doctor. His kindness basically saved my life. And I even cannot say thank you to him.

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    1. I wonder if Dr. Herz (love that name!) even realizes how his small kindness had such an impact on you. When I hear health care professionals explain that they don’t have enough “time” to be as caring as they’d like to be, I’m reminded of doctors like Dr. Herz – who probably took barely 10 seconds for his kind remark to you. Little things do mean a lot…

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      1. Exactly. We do not notice such things in everyday life. But while being sick, every tiny word or touch has a huge meaning.

        This doctor is still here in town, and I wish to send a grateful letter to him, but no way… Also, I am not sure he noticed this his action, — as every kind person who just does this and does not expect any gratitude for himself.

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  6. This subject was well addressed more than 40 years ago in THE PATIENT AS A PERSON: American Journal of Roentgenology …by J Scott Dunbar MD.
    Dec. 1972.

    This article discusses the reasons why “There is a real danger…doctors…may come to regard the patient as a necessary property to be manipulated in the conduct of medical affairs, or as a package for an interesting and challenging disease, rather than as a sick human being.”

    The author conveys his enthusiasm about academic medicine while encouraging his audience to consider the individual patient above all. Numerous excellent examples of how to do this are given. He summarizes, “This patient, this case, this diagnostic challenge, is a person, a human being with a mixture of fears, hopes, misery, trust in the doctors, and worries about himself; is not just a unit or package in a list of interesting case material.”

    Dr. Dunbar’s passion for his subject is obvious and infectious. Hospital care would be much kinder if every physician read this article – and lived by the philosophy it espouses.

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    1. Thanks so much, Jennifer, for telling us about Dr. Dunbar’s wonderful words! I agree – every modern doctor (and med student) should read his message. Contrast those words from 1972 to what I just read today, a stunningly misinformed editorial written by one Niam Yaraghi in U.S. News, criticizing patients who post online physician reviews (a post that’s been attracting an understandable reaction on Twitter):

      “Patients are neither qualified nor capable of evaluating the quality of the medical services that they receive. While the interaction between patients and their medical providers is an important element of the medical care process, it is not the most important one.”

      Thank goodness Yaraghi is not a actually a physician himself, but a recent PhD “expert” in health information technology, which apparently qualifies him to know all about patients.

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    2. Hi Carolyn, it’s Christine. I have a new blog; writing is good for me. Of course you know my feelings on the lack of kindness in health care after my journey from hell and back. But I must say there still is hope. I have a primary care physician that is really one of the most heartwarming people I’ve ever meet. I feel blessed to have searched for him. Seek and you shall find, I guess.

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        1. Yes it’s so great to have a doctor who treats the whole patient, I must say. In my area it seems rare. Check out my new blog. You might like it. Yes, blonde spelled the wrong way on purpose! 😊

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  8. I have several doctors who call me personally to talk about test results and are not offended by a patient who wants to be a partner in their own care. They encourage an educated patient and like to discuss treatment options. I feel cared for when my doctor listens and spends time with me.

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  10. Pingback: Minding the Workplace

  11. To get an insider’s view of how doctors view their patients, I recommend the novel “House of God” by Samual Shem. Although it was written in the late 1970s, much still holds true.

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    1. Thanks for that recommendation. I read that book ages ago (long before my heart attack gave me a sudden interest in how medicine is practiced!) It would be interesting to reread it now! In the 70s, many doctors called the book “cynical”, although Shem himself apparently disagreed, saying he was just “speaking out against the brutality of medical training.”

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  12. Important post Carolyn. It’s sad to me that kindness needs to be discussed at all, much less taught. If kindness and compassion permeated every interaction and was simply how humans treat each other on a daily basis, then this wouldn’t even be a topic.

    The nurse who put a gentle touch on your shoulder as you were being wheeled is a wonderful image for me of how to treat everyone all the time as we are all wheeled down the long corridor our life.

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    1. Love that analogy to the “long corridor of life”. Ain’t that the truth . . . I also feel sad about the need to even discuss kindness as if it’s some kind of groundbreaking new concept!

      I reacted the same way when I first read of Dr. Harvey Chochinov’s research that found (brace yourself for a news flash!!) – patients feel better when their doctors listen to them! The fact that some people apparently need to read this in a medical journal for scientific validation before they “get” that basic truism of humanity is indeed sad.

      Dr. C also emphasized the “Patient Dignity Question” which he dubs “the most important question” a physician can ever ask a patient: “What do I need to know about you as a person to give you the best care possible?” Wouldn’t that be fabulous if every doc asked that of every new patient?

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  13. Second story from neurosurgery. Different, but also told me that I was absolutely in the right hands:

    I had chosen my young HMO neurosurgeon because, obviously, he knew a great deal, but also because he was open about his own uncertainty. I already knew my case was not slam dunk. The Famous Doc (the one we paid to see out of network) told me that my tumor was not typical meningioma, could be a number of other things, and nothing would be clear until they went inside. The young surgeon also had demonstrated a warm sense of humor in our first appointment. Something about the way he told me that he absolutely did know that he’d give me a lousy haircut.

    While I was in the hospital, he popped in to see me frequently, and he came to remove a particular set of dressings himself. “This will tug a bit,” he said. “Think of it as a bad wax job.” I replied, “What’s with you? Bad haircut! Bad wax job! Good thing you showed some talent in neurosurgery! You never would have made it as a cosmetician.”
    And he laughed.

    The next day, my husband and I were both sharp enough to ask detailed questions about the surgical procedure. As the neurosurgeon answered them, so very much was sounding familiar to me: a long time machinist and aircraft mechanic. My husband was aghast that a piece of my skull was held by adhesive, but I knew how good and appropriate adhesives can be. I turned to my husband and said, “See? I told you that they really are mechanics!” Again he laughed, and acknowledged the point.

    The day of my discharge was his day off, but he came in and brought some of his instruments so I could see them. A different scale, but I confirmed that they were essentially the same as some of my corrosion removal and blending tools.

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    1. What a funny – and profound – story! Coming in on his day off?! That young neurosurgeon gets bonus points for kindness and consideration. His message was clear: “I was thinking about you…”

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  14. Two stories from my neurosurgery 3 years ago. First:

    I arrived on the neurosurgery ward, straight from the recovery room, wide-eyed and and talking nonstop (as I did for hours to come). This particular ward has a 2:1 patient to nurse ratio. My swing shift nurse took her time with my intake survey and listened carefully, even when my answers wandered from the question. I do have a complex history. Throughout my stay, she gave detailed turnover notes and intervened firmly whenever Normal Procedures simply would not do For Me. Like – I needed 3 aides to turn me until I could turn myself; my head and neck absolutely need special support.

    I am a lifelong stoic, and one evening when I was in terrible pain, through tears I persisted in saying it was a “7, maybe 8.” (Well, I have been in a lot of terrible pain, so that Worst Pain Ever is a high bar…” But that nurse looked at me and shook her head. “You…” And she went ahead and gave me what I needed.

    The next day I made a point of thanking her for that, and she said, “I know you. And you keep saying it’s a seven… Seven!“ Again she shook her head.

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    1. Kathleen, what really struck me about this nurse was the part where she looks at you and says “I know you…” Isn’t that what every patient truly wants and needs – to be cared for by somebody who has paid attention and taken the time to get to “know” us? That was a woman who took kindness to a new level!

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  15. This is so true. Simple acts of kindness make a huge difference. After I had my angiogram, the doctor, who was not my regular cardiologist but an angiogram specialist I think, told half-groggy me, still on the angiogram table, that my arteries were pristine but that I had cardiomyopathy. And he left. I had never heard of this. The poor nurses were left to answer my “Is this life threatening?” questions.

    But here is the great act of kindness I remember. When I went back to the ward, and had the lead removed from my artery and was clamped down, one of the nurses brought me a warm blanket. It was the most comforting thing that had happened that day, and I still, three years later, remember the comfort of that.

    My regular cardiologist does try to be kind, I think. But it is sometimes misguided. Unsubstantiated optimism I think. I kept being told my Ejection Fractin would return to normal in 3 months…. 6 months etc with medication. With some people it does, but not everyone. And then you feel like a failure, like you are doing something wrong when this doesn’t happen. I got over that feeling like a failure.

    So I think that my cardiologist is kind-ish, but I would have appreciated more realism about what I was dealing with. But still done in a kind way.

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    1. Oh boy… That angio story is a textbook example of an utter lack of kindness – drop the jargon bomb in a patient’s lap and walk right out the door! This is pervasively common – and not just in cardiology.

      Some docs would defend this inexcusable behaviour by pointing out that interventional cardiologists are busy, busy people who flit from one cath lab to the next all day long and simply don’t have time to think of each patient as a whole human being, lying there afraid and overwhelmed. But even the busiest and most important physician can learn how to appropriately transition from blurting out a diagnosis to leaving the room.

      When I worked at Hospice, our team taught annual courses to physicians, nurses and pharmacists; our most popular course was called “How To Break Bad News”. Just observing this class from the back of the lecture hall over the years, I witnessed many examples of what Dr. Anne’s comment below calls their “systematic desensitization of humanity in the mind and heart”. The encouraging news though: they’d all signed up to take this course!

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        1. I’m guessing that teaching how to break bad news and other challenging communication skills is a relatively recent curriculum addition in med schools. Even when med schools don’t teach it, however, some hospitals implement scheduled training for their employees (at the University of South Florida for example, Emergency Department residents are given mandatory five-hour grand rounds training in breaking bad news). This shouldn’t be a ‘one-off’ hit-and-miss kind of training, though – it should be as routinely taught in all medical education as taking blood, inserting drips or performing any other clinical skill.

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          1. “Even when med schools don’t teach it….” VOILA! This is at the core of the problem: At some (many?) med schools (and nursing schools), kind, caring behaviors may not have been modeled and emphasized during the course of initial degree programs.

            That program has an especially powerful socialization component, and it tends to occur during a point in people’s lives (mid/late 20s for doctors; early 20s for nurses) when they are, well, pretty caught up in themselves. They also may have scant idea, beyond occasional checkups and routine clinic visits, how powerless and scary it can feel to be a patient in a vulnerable situation. They simply haven’t been around the block enough.

            I see this with many law students I teach all the time. Analytically smart and ambitious, their emotional intelligence simply isn’t operating at a high level yet. And they have no idea how stressful it is to be a client in a high stakes matter that may involve one’s livelihood, business, or freedom.

            David

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            1. So true… This is why (in both medicine and law) those who practice are so often utterly gobsmacked when suddenly thrust into the unfamiliar role of client, no matter how many years of “expertise” they may have accumulated on the other side of the gurney/court room. I wrote about this for the British Medicial Journal here.

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  17. How does one teach kindness in a system that rewards only technological superiority?

    The medical training system begins with the MCAT test, where they have removed any general knowledge or essay questions, continues with the systematic desensitization of any humanity in the mind and heart in a numbing information overload in medical school, and finishes off with internship and residency, a brutal apprenticeship where I at least was instructed not to care for patients – I was even taken off a case for being “too deeply involved” as an intern.

    The usual United States-trained physician spends at least seven years of their late adolescence and early adulthood inside this socialization process and comes out the other side much less than kind. How does one teach kindness?

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    1. Thanks so much for your perspective here, Anne. It’s discouraging to consider that not only is kindness not being taught in most med schools, but it’s apparently being beaten out of students by 3rd year. Still, I’m encouraged by the words of Drs. Tomlinson, Montori, Heath and of course Lown – and also by medical school programs like the “kindness curriculum” at Michigan’s Oakland University. As one med student explained to the Detroit News:

      “Not only are they showing me how to be a kind and compassionate doctor, but they show me all the time how much they care about me as a person. They model the behavior that they want from us.”

      I think the question is not so much ‘how does one teach kindness?’ but rather ‘how does one get every single medical school to identify this as an important subject?’

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