Sunday, February 11, 2018

The Legacy of Kindness

Health care is always delivered by a team.  The more complicated the clinical condition-- the more education or training involved in our care-- the larger the team.   Even when we are alone in the room with our patient, there are people outside the room who are arranging for labs and referrals, preparing a room for the next patient, answering the phone, giving shots or drawing blood, and most certainly there are people seeing to the details of insurance coverage, billing and collections.   Clear communication and efficient coordination across care teams are always a challenge. 

Some of the children I care for have 20 or more active participants on their team.  And the teams extend well beyond the walls of our clinics and hospitals.  Consider the special education teacher who supervises a g-tube feeding for her student, or the school nurse who gives daily medications that help to control my patient’s dystonia, or involuntary drooling or seizures.   Think about the whole range of in-home services for occupational, physical and speech therapy.  Respiratory therapists work with my patients who live at home on mechanical ventilation.  Care coordinators help to organize services and appointments and transportation.  Social workers are essential for support and the application for essential benefits.  Psychologists work with behaviors and coping strategies. 

Many of my patients have as many as 8 or 10 subspecialists who guide treatment and diagnostic work-ups.  It can be a dizzying array of people and personalities, each with a unique and active role on the team.   The families who need to manage the workings of a complex care team have seemingly countless opportunities to receive kindness or encounter more struggle.

Sometimes we--as individual members of the care team-- forget or underappreciate the vastness and complexity of the team.  We may overlook the synergistic stress that accumulates for the patient and their family caregivers as they move from appointment to appointment, decision to decision, fear to more fear. A routine appointment to discuss insufficient weight gain, could very well be a moment of brutal reality for a care-giver.  Despite arduous attempts, over months or years, with many skilled providers, their beloved child is not thriving, and today is the day when the realization hits home.

The kindness required at these points is no less necessary than at other moments.  A kindness deficit, however, is going to be glaring and memorable.

Kindness in the face of synergistic, cumulative care-giver stress can be as simple as a moment of silence.  Sitting quietly, with compassion for the emotion in the room, is a way to practice kindness.  Allowing for the care-giver to ask the same question over and over, as they try to take in what is being said, is another way to communicate kindness.  Stating clearly that we are not going to abandon the patient and their care-givers, when we have exhausted all currently available therapies, is perhaps the ultimate kindness.

When my wife is the attending physician on an in-patient care team, she meets with the medical students first.  She outlines her expectations for their successful and active participation on the team. Among her expectations are that they model kindness and compassion in two concrete ways.  First, they must include one descriptor that humanizes the patient.  “Mrs. X is a 32 year old English professor whose specialty is Dickens.  She is being admitted for.. . .”  “Mr. Y is an 82 year old grandfather of 12 who is very concerned about his dog Rex.  He is being admitted for . . . .”

The second required practice of kindness for medical students on my wife’s team is to be sure that the patient is put back together before the team leaves the room, and to ask the patient directly if there is anything more the team can do for them before they leave.  The student is responsible to model for the team these simple acts of kindness.  “Mrs. X, can I help you get your gown tied?  Here, let me get your tray table back in front of you so you can finish your breakfast.”  As the team prepares to leave the room, the student is expected to step up and ask, “Mr. Y, is there anything else we can do for you before we leave?”

My wife says that invariably the patients and their families are grateful, often returning the offering of kindness with their blessings for the team and their day.  “No, I don’t think I need anything else right now, but thank you for asking.  And you all have a blessed day.”
 There is, quite often, a ripple effect from the student’s kindnesses, as residents also begin their introductions with a humanizing adjective or clause.  In fact, there have been teams who get a little competitive to see who can discover the most insightful patient descriptor.  “Mrs. Z is an 88 year-old former Army nurse, who met her husband on a hospital ship during WWII.  She is being admitted . .”

Students remember these experiences of kindness.  Certainly, their offerings of kindness humanize the patients, who will ask for the student by name even after the student has moved on to another rotation.  The acts of kindness and consideration also humanize the students as future doctors.  The practice of kindness allows the student to build deeper trust and connection with their patients.  The complexity of the patient’s illness or disability is set in the legacy of a life, and encountered as another human being with whom they have a unique and privileged relationship.   Offering kindness has its own profound legacy.

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