This essay is based on the talk I was asked to give at BadEMFest18 in South Africa. When I submitted my pitch I suggested I could talk about ‘something to do with paediatrics… or anything really, I’m happy to help out‘. Then I opened the DM from the team and found that I was given the nearly impossible challenge of reminding the delegates ‘How to be Kind‘. In order to distil my thoughts down to a succinct 15 minutes, I thought I’d let you in on what I’ve been thinking about.
What is kindness?
Kindness can be really tough to define.
Perhaps it is easier to talk about the opposite of kindness? – the rudeness we display towards others, the curtness, the incivility. We’ve seen how disruptive doctors make it hard to work together as a cohesive team. We’ve seen angry relatives jab fingers at a nurse for not being at their beck and call. We’ve seen in-patient unit registrars roll their eyes when a ‘fresh out of medical school’ intern stammers through their first referral. Someone shouting at you for making a mistake is going to hamper your work, but researchers have also found that just being uncivil also has a negative impact on performance.
In a simulation-based study, making derogatory comments about the subject’s medical training led to a marked drop-off in successful outcome measures. Perhaps this is another example of the stereotype threat at work. Doctors and nurses are told they are no good, and so they try too hard and make mistakes. The researchers suggested coming up with ways that “... offer a means to mitigate the adverse consequences of behaviours that, unfortunately, cannot be prevented…”
So is ‘being kind’ just not being rude? We might walk past as a junior member of the team gets berated for a mistake, not wanting to get involved. How about showing a little kindness? I think kindness is moving beyond the casual indifference of an empty glance towards making a connection, a bond, however momentary, with another human. It is what Archbishop Tutu would call ubuntu.
A culture of kindness
Creating a positive workplace culture, leading to more acts of kindness and organizational citizenship behaviours (OCB) in the parlance of psychosocial research is not just the responsibility of the individual. It is the responsibility of the organization itself. Researchers at Google found that when their team’s actions were rooted in fairness, trust and cooperation, more OCBs occurred. But when rude or uncivil behaviours were witnessed in an authority figure, there was a drop in prosocial acts within the team.
It seems that kindness is contagious. One positive act begets another to form a potential virtuous circle of goodness. You may have seen the film Pay it Forward, with Haley Joel Osment, that takes this principle to Hollywood levels of excess.
In hospitals, there tends to be a culture of apathy, of “it’s not my job“, as if we are inured to the human suffering around us. Meal trays are placed just inches out of reach, and requests for another blanket are ignored. If we just stop for a moment and recognize that the human being making the request is somebody’s mother/father/daughter/son, we might jolt ourselves out of this apathy.
It can certainly be a challenge to be kind if you are the only one doing it, but that does not mean you should not try. Like the anti-vaxxer who is determined not to immunize their child against measles, the apathetic bystander, by not being kind, allows bad behaviour to spread.
Don’t ‘nice guys finish last’?
It’s important not to conflate being nice with being kind. Nicety is a societal construct designed to give power to those who do not have any. We are nice because we want people to like us. We are nice because we crave external validation. We are kind because we want to be, not for anyone else, but because it is the right thing to do.
You might think that kindness is an act of unselfishness, but such prosocial behaviours can be beneficial to the giver as well as the receiver. We know that small, everyday acts can lead to a sense of greater connectedness with loved ones or colleagues, especially if they are freely given, without obligation. It makes sense that if you feel happy, you are more likely to be kind, but the opposite is also true. Just performing an act of kindness, whatever you feel inside, can also improve your mood.
There is much to be said, also, of the evolutionary benefits of kindness. With Richard Dawkins’s assertion that we are all here to help pass on genetic material from one generation to the next, we should consider the ‘unselfish gene‘.
The evolutionary benefits of kindness
Consider that the etymological derivation of the word ‘kindness’ is ‘kin-ness’. Performing an act of kindness was seen as performing an act that drew the tribe together, perpetuating the line. How could this be so?
Kin altruism
Whilst Darwin may have written about the survival of the fittest, he believed that humankind was a profoundly social and caring species. It seems that kindness to one’s kin, even the weakest of the tribe, could allow the passage of shared genetic material. Experimentally, this has been demonstrated by showing that men are more likely to donate to charities using images of children that have been digitally altered to resemble their own. They think they are helping one of their own tribe.
Mutualism
When we roamed the wilds as hairy hunter-gatherers, mutual coordination would have been the only way to bring down big game. This is the “I’ll scratch your back…” approach to kindness done purely out of explicit self-interest.
Reciprocal altruism
Mutualism implies an action carried out for a common goal, whereas sometimes people are kind in the hope that karmic balance will restored at some point in the future – I perform a kind act today in the hope that someone else will perform a kind act for me in the future.
Competitive altruism
And finally, there is the proposition that being kind is, in part, a way of displaying one’s status, in the sense of noblesse oblige or, using a more popular frame of reference, with great power comes great responsibility.
So then, it all boils down to this… We know kindness is good for others (and ourselves), so can we teach it?
I believe we can.
Children begin their lives as naturally kind beings, but as they grow into doctors, nurses and paramedics, something happens to them. The introduction of a kindness curriculum to younger children promotes prosocial behaviour.
Perhaps this is why the Sesame Street Workshop introduced kindness as the theme for its 47th (2017) season. So what can we do? We can role-model kind behaviour, but I want to be more explicit about how we can act kind. More on that next time.
If you woke up one day and found that you were the only person left in the entire world, you still need to be kind. We think of being kind as something we do to others – our patients, our colleagues, our loved ones – but it is also something we need to do for and to, ourselves. If we cannot be kind to ourselves, then what?
If you read the footnotes you will know that I am a huge fan of Jean-Pierre Jeunet’s Le fabuleux destin d’Amélie Poulain. Whilst my French is a little rusty, I think Il est préférable d’aider les gens que les nains de jardin, sums up it up perfectly. Rather than the standard ABC-based approach we use for nearly everything in medicine, I’ve come up with something else that may be just as familiar if you have children of your own.
In this modern world of push notifications and always-on, always available, you could be forgiven for thinking there is no time for social niceties and that you should just cut to the chase. We are forever rushing from one place to another, our attention often not on the now but on the ‘five minutes from now’. Acknowledging the myth of multitasking we try to rapidly switch our focus from one thing to another, eyes saccading from ECG to the computer screen to monitor to drug chart and, occasionally, to the patient in front of us.
I want you to STOP. Be in the moment with your patient and their families. I want you to put down your pen and pay attention. Me asking you to display mindfulness may have some of you shaking your heads. I’m not asking you to crack out the pencils and the fancy colouring books. I’m asking you to use mindfulness as Jon Kabat-Zinn, one of the founding fathers of Mindfulness-Based Stress Reduction, would define it.
It has been shown to be beneficial to both the practitioner and the patient, enhancing communication, increasing empathy and increasing affect tolerance. I’ll explore mindfulness at a later date, I’m sure, but for a primer on how you can relate it to your everyday practice, listen to Scott Weingart’s talk at SMACCDub.
We have all heard that the words we use only convey 7% of the information we want to put across. Our non-verbal communication helps tell the greater truth. If you do not LOOK for it, you will not see it. Looking at the person in front of us allows us to pick up on their distress and concerns.
Pollack et al. videotaped 398 conversations between oncologists and their patients and found that the doctors missed empathy cues 22% of the time. When we look at someone’s face (and not at their notes), our brains integrate microscopic cues that allow us to make social judgments, such as trustworthiness, in just 100 milliseconds. We should also bear in mind that our patients are doing the same thing. A patient is subconsciously judging you on your level of sincerity and engagement when they are looking at you.
The 7% rule
Back in 1970, Albert Mehrabian published his research on non-verbal communication in a book called Silent Messages. The students he studied assigned 7% of their assessment of credibility to the words used, 38% to the tone and timbre of the voice and the remaining 55% to the speaker’s body language. This is clearly untrue, as no amount of mime skills will be able to get your point across. And like everything that we assume to be true, it is worth going back to the original literature.
In the original experiments, the subjects had to listen to a woman’s voice saying ‘Maybe’ and state whether she was conveying a sense of liking, disliking or neutrality. They then had to guess the emotions when looking at a photograph and listening to a spoken voice. Subjects were better at determining the emotion when they had visual as well as auditory cues.
Jeff Kline also posits that just looking at patients might help us determine if they have a pulmonary embolus or not.
It is easy to look at the list of patients waiting to be seen and groan as you think of ‘not another vomiting child’. Those of us who have been working for some time can become inured to the suffering of others. Damian Roland gives some great examples of how not all children are the same here. We make judgements based on triage notes. We presuppose what a patient is going to be like. Try going to see a patient and not reading their note first. See how that guides your encounter.
I was once at a course and, as is usual, after a talk, the speaker asked a question, and then waited…and waited…and waited for a response. He made a conscious effort to wait 7 seconds before answering.
This phenomenon, known as ‘wait-time‘, has been widely studied by educationalists. We generally wait no more than a second before following up with an answer or trying to put one into our patient’s mouth.
Simple questions – the yes/no’s – need no more than three seconds of wait time to yield accurate results but what about more complex ones?
In a lecture setting, it has been suggested that there shouldn’t be a limit on the wait time after a complex question. The agonizing silence, occasionally interrupted by a ragged tumbleweed blowing across the stage, helps learners come up with deeper, richer answers.
When we are talking to patients, too, there is value in letting them talk out their stories. You might think taking a history is going to take forever if you let the patient rabbit on. Actually, the data suggests that just increasing the wait time to more than three seconds allows subjects to get into their stride, pull their thoughts together into a functional narrative, and shorten the duration of the interaction.
Data from Beckman and Frankel has shown that, on average, a doctor interrupts their patient within 18 seconds of them talking. In these days of four-hour targets, we might think we are saving ourselves time by cutting to the chase. What could have been a long and detailed history becomes an interrogation as closed question follows closed question until the doctor is satisfied that they have heard enough. All patients, all people, have a story to tell. It might be about their illness, about how they fell off the trampoline trying to impress the girl next door, about how they are scared every time they hear their parents argue. If you do not sit and listen, you will never know. I sometimes tease our interns when they present a patient to me…
Junior Doctor: Mr X is a 54-year-old male who developed central crushing chest pain whilst at the cinema. He felt diaphoretic and nauseated, and when the pain wasn’t relieved by his usual GTN, he decided to call an ambulance…He received 300mg of aspirin and 5mg of IV morphine and is now pain-free. He has a normal ECG, and his troponin is pending.
Me: What was he watching?
JD: What?
Me: What was he watching? Was it a scary film? Did he miss the end?
…and so it goes on.
For most patients, children and adults alike, a visit to the hospital is the most important (and/or interesting) thing that will happen to them that year. Let them be the central actor in the play and allow them their time to monologue. LISTEN, as Stephen Covey would suggest, with the intent to understand, not the intent to reply.
So, how can we practice active listening?
Start by not interrupting and allowing the patient or their caregivers to have their say.
Use open-ended questions when possible before drilling down on the finer points.
Ask, “Tell me more about that?” or “How did that make you feel?” and wait… and wait… and wait some more for an answer.
Check your understanding of the answers, “So, what you are saying is….”, ‘Let me see if I have got this right ….”
I’ve said that everyone has their own story to tell. What if their life experience is so divergent from your own that you cannot communicate in the same language? A better understanding of your own inner world has been shown to improve your ability to see things from another’s point of view. This was brought home to me after a truly life-changing event. Bad things happen, but often, we don’t talk about them (or write a blog post on them). Those “over-protective parents“? Perhaps their first daughter died, and they are petrified that something as random will happen again. To a patient there is no such thing as a trivial consultation, please try and remember that.
There are always going to be patients and families that, for some reason, we just don’t like. But that does not mean we should not treat them with kindness. We have a tendency to blame some patients for the disease they have – it’s called the fundamental attribution error. Before we rush to pronounce judgement, it is time to THINK of some of those biases that we hold that might be affecting both our judgement and our behaviour. (If you really think you do not fall into this category then I suggest you read this thought-provoking post from Simon Carley on implicit association).
All it requires is for you to act kind. You don’t have to love or even like the person you are being kind to (though it does help). Working in a mixed emergency department, I see people whose lifestyle /pharmaceutical /nautical language choices I do not agree with, but that does not mean I should stop being kind to them. The same goes for my online life. There are people I follow on Twitter that I do not agree with, but I don’t want to turn my tweet stream into a self-congratulatory echo chamber. I need people to push back every now and then to make sure I don’t walk around covered in FIGJAM.
Every day, we are presented with opportunities to be kind to ourselves, to our partners, to our patients. Give it a go.
But I’m shy, I can’t go up to a stranger?
I’m fully aware that I am an introvert and draw my energy from time alone (and writing, as you can tell), but I’m sure that there is a degree of social anxiety involved in my dislike of crowds. That is why I was really interested in reading a study by Alden and Trew that demonstrated that performing random acts of kindness actually reduced social avoidance in socially anxious individuals.
Perhaps this is another one of those “Fake it till you make it” situations where being kind acts as positive reinforcement for the act of talking to a stranger.
But if the thought of going up to someone is really giving palpitations, consider another kindness, perhaps championing the suspended coffee movement, where you can still bring a little light into somebody else’s day. Or perhaps you would feel better by donating to charity in the hope that you can do a greater good? Check out Effective Altruism and see how far your money can really go.
At the end of the day (or the week), sit and reflect on those acts of kindness and how they have made you feel. It’s an exercise I am trying out with my two eldest children (currently 6 and almost 4) as a way of cultivating a culture of kindness at home. Let me know how it goes…
Hit us up in a tweet or in the comments section, and include the hashtag #DFTBkind
Some Footnotes and Further Reading
Films
About Time (2013) dir Richard Curtis – Please can everyone watch this, if not for Rachel McAdams, then for the lesson of the last fifteen minutes.
Le fabuleux destin d’Amelie Poulain (2001) dir Jean-Pierre Jeunet – One of my all time top ten films ever. You will forget it is in French as you are drawn into the world of Amelie Poulain, a young waitress who only wants to do good.
Cinderella (2015) dir Kenneth Branagh – Have courage and be kind – ’nuff said.
Pay it Forward (2000) dir. Mimi Leder – Haley Joel Osment, playing a less creepy but just as intense a child as he did in The Sixth Sense, tries to change the world.
Books
Brown, Derren – Happy – What appears to be a bright and colourful book on happiness is really a deep philosophical dive into Stoicism in the modern era.
Frankl, Viktor – Man’s Search for Meaning – This is one of those books that most of us have heard of but never read. Do yourself a favour and pick up a copy.
Jeffers, Oliver – Here we are – I’ve loved all of his work, especially The Day the Crayons Quit and this book is no exception. It’s a simple yet beautifully drawn instruction manual for a new life.
McCloud, Carol – Have you filled a bucket today? – Sometimes, a children’s book can put in 32 pages, but a professional philosopher cannot put in 400.
Palacio, R.P – Wonder – A couple of people had recommended this book to me, and I read it over a weekend. I only cried twice.
Thackeray, W.M. – Vanity Fair – This 1848 collected serial of life in England during and after the Napoleonic wars is one of the few books I re-read every couple of years. Everyone knows of the anti-hero, Becky Sharpe, but to me Dobbin is the true hero.
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Andrew- thank you for highlighting a really important issue in this post. The Cinderella quote ‘Have courage and be Kind’ is one my personal mottos!