By: Dr. Lorraine Dickey
As a physician I have been a student of the basic sciences my whole academic career. Biology, Physics, Mathematics. I have been trained to be logical, objective and to use the scientific method to understand my work. I am an Apostle of Data. Indeed, it is for these very characteristics that I am a highly valued person in our society. This is what I offer my patients. More importantly this is what I have been taught my patients expect and deserve. One set of biologic data should lead one physician to make the same diagnosis as another physician. After all, fundamentally, a cold is a cold and a stroke is a stroke. Patients count on physicians for this objectivity. Medical systems demand efficient actualization of this training. Diagnose, treat, repeat.
Most of us come to the profession of medicine with good hearts, strong minds, kind dispositions and only the best of intentions. Yet the demands of learning to diagnose and treat…with repetitive accuracy and skill… is all consuming. Medical training programs don’t boast about how kind they are to their interns, residents, or fellows while they learn these skills. It’s as if one’s experience with the world outside of medicine is put on hold for 10+ years just to gain the basic competencies expected of a junior physician. The development of personhood is suspended. If kindness begets kindness, then unkindness begets unkindness. The adage that “child abuse begets child abuse” thrives in the core of medical culture as much as it thrives within the military. “If I worked 36-hour shifts, then you can too.” “Suck it up, buttercup.” At some point fatigue begins to win. Survival skills kick in. To some extent our basic human kindness gets trained right out of us. In some cases, not all survive as evidenced by the absolute tragedy of suicide during medical training programs.
Once training is completed the newly minted physician is flushed into the vast ocean of medical practitioners with its multi-generational values, biases and expectations. In addition to the cultural expectations of long hours and hard work, there is increasing administrative and financial pressure on performance for revenue, seeing more patients per day. In this environment being objective during the patient-physician encounter is a survival tool for physicians. Our training has prepared us well.
Yet as a physician I have a duty to be kind and compassionate, not merely diagnose and treat. My patients want me to comfort them, be empathetic, and yes, even human. How can I do this yet remain objective, efficient, and on-time? The simple reality is… I can’t. At least not all the time. Compromises will need to be made. There will be collateral damage. Is there any duty that I be treated with kindness and compassion as a physician? Administrations are not obligated to mitigate the collateral damage that is inherent in being a practitioner, physician or other healthcare professional in today’s healthcare environment. Patients are not duty-bound to treat me as their physician with kindness and compassion, with sympathy or empathy. And colleagues can provide some of the most exquisitely unkind acts of all. Is it possible to be kind and compassionate in a system that does not treat me with kindness and compassion? Is it possible to remain kind and compassionate in a healthcare culture that does not seem to value kindness and compassion?
So here is where the rubber meets the road. Here is where the business of medicine needs to meet the expectations of the patient and physician. As third-party payors continue to value “quality of care” over “fee-for-service” models, the voice of the patient continues to gain momentum. Voices of physicians experiencing burnout are also gaining volume. The patient-physician encounter is becoming less of a calm interaction and more like the site of a collision of people going 65 mph in cars poorly equipped with safety equipment. Both may well leave the encounter with wreckage to repair.
At this point I should let you in on a little secret. I’m writing this as both a physician and a long-term patient in the healthcare system. I experienced burnout as a senior Neonatologist to the point where I left Neonatology after 25 years and went back to training at the age of 51 in a field of medicine that I felt was more compassionate and more humane, Hospice & Palliative Medicine. I’ve survived a catastrophic ski accident with a significant traumatic brain injury and cervical spine injury that left me out of work for 2½ years as well as treatment for breast cancer (surgery, chemotherapy and radiation.) I’ve experienced kindness and compassion, and the lack of them, from the perspectives of an intern, resident, fellow (twice), seasoned neonatologist, HPM physician as well as a long-term patient, mother, wife, daughter and friend. I am no longer unbiased nor a novice in my profession or in my personal life. I have learned the value of this saying first-hand:
“I’ve learned people will forget what you said,
People will forget what you did for them,
but people will never forget how you made them feel.
-Maya Angelou
Despite my training in the value of being objective, my life has taught me objectivity by itself is insufficient. I need to adapt to meet the broader, more subjective expectations of my patients. To do this I need different skills. I need to learn to listen differently. I need to listen more efficiently and effectively with less bias, fewer expectations. I need to understand what my patient needs from me other than my diagnosis and treatment plan. And what I have learned is my patient and I BOTH need a better patient-physician experience, a kinder experience, not simply a different type of encounter.
For a moment let’s consider a very different area of science. Phenomenology is the study of human experience where the considerations of objective reality are NOT taken into account. Objective reality exists when you and I and others can both agree something exists. “This is a rock.” “Yep, that’s a rock.” Perceptual reality is different and yet inherent and necessary to our everyday lives as individuals. Perception is how I experience my reality and it differs from how you experience yours, even while we are in the same place at the same time objectively experiencing the same thing. For example: my patient and I are both at a 10:00 a.m. appointment. I am running late. I’m 10 minutes behind schedule because I needed extra time to comfort a grieving patient 30 minutes ago. My perception: I’m doing the best I can. My patient has an 10:45 a.m. bus to catch so she can pick up her daughter at pre-school. She really needed the 10:00 appointment to start at 10:00. She knows this flare-up of her chronic asthma will take more than the usual 15-minute appointment. Her perception: Late again! What will I do if I miss the bus? I’ll have to skip getting any medications and try to get them tomorrow. It is my perception that I am being as kind as possible, hurrying as much as possible to be only 10 minutes behind though I may be perceived as unkind and discourteous by being 10 minutes late. Our perception is our reality. Only when our perceptions are similar are our realities similar.
Fundamentally kindness is an experience, a perception. Two people are needed for a kindness to be perceived. As I walk the aisles of my local grocery store I cannot find a jar of kindness even in the organic area. (It is true that you can be kind to yourself though that experience is not discussed here.) Any act of kindness has three requirements: an act, an intention and an agent. Kindness can take the form of a kind act, spoken act or physical gesture, or a kind act of omission [i] (example: my patient not mentioning that I am objectively 10 minutes late.) The agent of kindness must offer the act with the intention to benefit another, to act in the interest of the welfare of another. There is a selfless quality to a kind act or a kind act of omission though it is not necessarily without self-benefit.
So, what is ”Medical Kindness“? While this term doesn’t really exist I offer that perhaps it could refers to a type of kindness “administered” by a physician to a patient with the specific intention of being therapeutic, if not curative, in nature. By definition: “Therapy is the act of caring for someone.”[ii] If this is true, then couldn’t all acts of kindness be consideted to be some form of therapy? Do we not intentionally offer kind spoken acts, kind physical gestures and perform kind acts of omission as ways of benefiting the welfare of another, of “caring for someone?”
As a physician, and a patient with no choice but to seek care in our current health care system, I offer that Medical Kindness could be prescribed for every patient by their physician as an inherent part of their patient-physician relationship. Simply take a prescription pad and write: “Please administer Medical Kindness” with 99 refills. The patient could then bring that prescription to all future health care appointments just like you would present a prescription to the pharmacy for antibiotics or to the Radiology Department for an MRI. I suspect a tangible, transferable, yet simple prescription may serve to heighten the awareness of the physician and the patient to the fact that BOTH should act as agents of kindness in their spoken acts and physical gestures during their time together.
Could something this simple help me as a physician meet the subjective kindness and compassion needs of my patients? Could presenting a prescription to “administer Medical Kindness” at the beginning of an appointment help us both to put the brakes on to avoid the impending crash of the patient-physician encounter? Might this be able to reset the expectations of the appointment and lay a foundation of hope for a kinder, more compassionate interaction? If I could present this to my administration would they be more willing to help meet my need to be treated with kindness and compassion while working as a professional in the current less-than-kind and highly stressful healthcare environment? I really don’t know... but wouldn’t it be wonderful if creating a culture of kindness in healthcare could be jumpstarted with something as simple as this?
Lorraine A. Dickey, MD MBA
Founder and CEO
The Narrative Initiative, LLC
[i] WS Hamrick. Kindness and the Good Society: Connections of the Heart. State University Press of New York. 2002
[ii] Advanced English Dictionary and Thesaurus. 2017