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 near-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 I thought would be a thousand words or so blew out into 5000, hence I’ve broken it up into a couple of posts. This is the second post – the HOW.
If you read the footnotes to my last post 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 that 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 that there is no time for the 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 then 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 someones 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 the 1970’s 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?
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 care-givers 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 blogpost 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 that 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 to read 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
Really, you want more? This space is left intentionally blank for reader suggestions.