Kim Oates: Case for kindness

WAY back in my intern days, it was unusual for consultants to talk with their “public” patients, apart from a quick comment on a ward round. The hard stuff was often left to us — the interns, young people with minimal life experience, an overwhelming workload and no training in the gentle art of communication.

At my teaching hospital a time was set aside once each week when family members could come to the hospital foyer, page the intern and ask questions about their loved one’s condition.

In my third month after graduation I assisted at a laparotomy on a fit, active 54-year-old man who presented with a hard lump at his umbilicus. The laparotomy showed widespread cancer with multiple metastases. The surgeon closed the wound. There was nothing to be done.

That afternoon happened to be the one when family members could meet the intern. It was my job to tell his unsuspecting wife when she came to the foyer to ask about her husband’s operation. I told her the truth as kindly as I could. Her eyes welled up with tears. So did mine.

Afterwards, I felt embarrassed about my show of emotion.  Why couldn’t I be “more professional” like my consultants? I wondered if I was really suited to do medicine. Later, I realised that it may have helped her. She may have seen that even though the news was bad, I cared.

In subsequent years, as a consultant, my eyes would sometimes moisten when I had to tell a parent that their child would not survive. And sometimes it happened when I had the pleasure of giving unexpected, but joyful news.

Was this behaviour “unprofessional”? Or is there is room for families, junior doctors and medical students to realise that we, the more senior doctors, do care? To realise that there is more to it than striding the narrow catwalk between aloofness and overfamiliarity, that there is a place to show humanity and that it is not unprofessional to let people know we care.

However, when clinicians show compassion which may extend beyond what is normally seen as “professional” they may be criticised. Dr Gordon Schiff, the associate director of the Center for Patient Safety Research and Practice at Brigham and Women's Hospital in Boston, Massachusetts, recently described an incident when one of his patients had problems negotiating the complex US insurance system to be able to pay for her medication.

Schiff decided that it would be kinder, instead of saying “I’m sorry, I can’t help you”, to reach into his pocket and hand her the $30 she needed to be able to fill the prescription he had given her. He did so. To his surprise he was reprimanded for “unprofessional boundary-crossing behavior” after the resident he was supervising at the clinic shared this incident with the clinic director.

Of course, there are some professional boundaries which we must always respect. Boundaries which prevent us from offering unrealistic expectations, from acting in ways which are of dubious legality and from confusing personal and professional relationships, particularly in the sexual realm.

However, these well accepted boundaries are different from really caring about our patients and doing something about it. Schiff argues that too strict an interpretation of professional boundaries “risks encouraging detached, arms-length, uncaring relationships” with this type of bounded thinking serving “to rationalize abdication of our professional and personal responsibilities to humanely respond to patient suffering and underlying injustices”.

We don’t have to take off our compassion, or our ability to show it, when we drape a stethoscope around our neck. The need for doctors to be professional is not synonymous with being emotionless.

There is more to this than just being nice to people. It is about being kind. It also has implications for the quality of patient care.

The 2013 Francis Report on the Mid Staffordshire NHS Foundation Trust Public Inquiry found that patients had died from avoidable causes and that many more suffered unnecessary indignities and harm. The report concluded that there was “an apparent lack of compassion among healthcare workers” at the hospitals.

An expert panel formed to respond to the inquiry findings recommended that the quality of patient care, especially patient safety, must be the aim above all others. In view of this priority, it recommended that patients and their carers should be engaged, empowered and heard everywhere and at all times in the health system and that clinicians and administrators must insist upon, and model in their own work, thorough and unequivocal transparency in the service of accountability, trust and the growth of knowledge.

Powerful recommendations — listen to patients; model transparency; model trust; keep on learning.

 

Professor Kim Oates is the director of undergraduate quality and safety education with the Clinical Excellence Commission.

This is an abridged version of an article published this month by the Royal Australasian College of Physicians in the RACP News magazine