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.

Anticipatory Kindness

As a child growing up in Northeast Ohio, going to Cleveland was a really big deal.  It meant driving along the Shoreway which was the one East-West highway with 6 lanes, 3 in each direction. My mother hated the merging traffic and the dire threat of getting lost Downtown.  So we did not go to Cleveland often, and it was a special occasion filled with excitement and intrigue, when we did.  Lucky for me, the Indians played ball on our side of town.  We also made it to the West Side Market twice a year, at Thanksgiving and Christmas, to shop for clementines, sour lemon drops, bulk nuts and chicken hearts.  

When my mother called to say that Dad was being referred to the Cleveland Clinic, I was already a young doctor in training.  He would need to see the cardiac surgeon for possible bi-pass surgery.   My mother never asked me to come home, but I did.  I knew she would need support, and a driver to get to and from Cleveland.

Dad’s dementia had become more apparent and his mobility was shaky at best.  Both of my parents perseverated about what the doctors were going to say and what was sure to happen.  My father, God rest his soul, was the ultimate pessimist, and mom the fatalistic denier.  The drive to Cleveland seemed the least of our worries, but my dutiful mother spread a giant map across the dining room table to plot our course.  I love maps so this was fine with me.  I was also quite grateful to discover the simple driving directions provided in the welcome packet that accompanied the letter confirming their appointment. 

I was living in Boston at the time.  I had lived and worked in metropolitan New York City, and I actually knew my way around London, but I felt like a kid again when we started off for Cleveland.   Turns out, Cleveland is pretty easy to navigate as an adult.  Still, I worried about finding our way around a vast hospital complex with parking, labs,  X-rays and multiple appointments, all potentially in different buildings.   And there would be the decision-making, the need to translate doctor-speak, and the anxiety of my parents to contend with.

Can you imagine my relief when we rolled up to the hospital entrance, and a friendly man in a bright red coat opened the passenger door, introduced himself, and suggested I allow the valet to park my car?  “Yes sir,” I said. “Thank you very much.”  When I showed the red-coated man our appointment notice and asked if he could direct us to our first stop, he smiled and said he planned to show us the way.  This friendly man in a bright red coat produced a wheelchair for my dad, and we were off through the halls of the Clinic, comforted by his jovial conversation about our drive into town.  He showed us the cafeteria along the way and before we even knew what had happened we were in a waiting area with abundant natural light, thanking our guide for his kindness.

This is what I call institutional kindness.  It is also an example of anticipatory kindness.  My guess is that nearly everyone arriving at the Cleveland Clinic is nervous or worried about something.  Offering a wee touch of kindness, let’s say in the form of a jovial man in a bright red jacket, is bound to improve the overall patient experience.  Kindness helps to put us at ease, and allows us to be less anxious, maybe even a bit more open and focused on the decision-making that lies ahead.  The institutional kindness offered that morning at the Clinic worked for me, and has remained an indelible, positive memory of health care.

Anticipatory kindness is akin to what we call anticipatory guidance in pediatrics.   When parents bring their children to me, they expect to talk about the child’s growth and development.  They look to me to help them interpret the child’s behaviors, and forecast what is to come. We talk about sleep, and tantrums, and separation anxiety, dietary preferences and teenage autonomy BEFORE they have become a problem.  I try to anticipate their needs, while guiding a path forward. 

So too, our challenge is to anticipate the need for kindness.  The Cleveland Clinic has chosen to post friendly folks in bright red coats at the entrance to their hospital, to serve as literal guides and certainly as ambassadors of kindness.  At the University of Virginia, the lobby is newly decorated with giant murals of inclusion and welcome. Therapy dogs visit the units and rest near the cafeteria.  Quite often I hear someone playing the grand piano in the main lobby, next to the surgical waiting area.  It's all a great start toward offering institutional, and anticipatory kindness.  

My wife had a terrific idea to increase the hospitality felt by patients in her clinic.  What if we replaced all the little signs requesting payment at the time of service, with brightly colored signs welcoming our patients like honored guests?

What if we anticipated the need for kindness at every step through the maze of our health care systems?  I suspect we might stumble over all manner of ways to offer kindness, creating increased ease among our patients, staff and visitors.  I imagine we would see positive changes in job satisfaction, patient satisfaction, and patient-doctor communication if everyone’s heart were just a little more open.

Jim