Reprinted courtesy of The Journal of General Internal Medicine
by Steven M. Asch MD, MPH, Dale V. Atkins PhD, Psychology, PC & Anne Walling MD, PhD
“Ultimately, the secret of quality is love,” declared Avedis Donabedian, a pioneering systems thinker and the father of modern quality assurance. Few in health care would dispute that compassion is an ethical requirement for good practice, and for most that provides enough motivation to act kindly towards patients. But does it work? To put it more dispassionately, what is the evidence that kindness improves medical care?
The evidence is surprisingly strong. Patients who perceive their doctor as empathic (empathy is distinguished from kindness or compassion in that it is an attitude rather than an action) have better outcomes. They take their medications more regularly, have higher self-efficacy, and have better control of their chronic diseases. Many view patient satisfaction as an end in itself of medical care, and kind doctors certainly engender more satisfied patients. Empathic doctors even practice more cost-effective medicine. And of course, as patients near the end of their journey, kindness may be medicine’s main offering. Moreover, the benefits of kindness redound to the provider as well. Acting kindly lights up the reward centers of the brain, and kind physicians experience less burnout. Perhaps even more impressively, the relationship between kindness and these outcomes is not just cross-sectional. Several kindness-promoting interventions are supported by randomized controlled trials. Two recent books summarize this line of work, the War for Kindness by Zaki and Compassionomics by Treziak and Mazzarelli.
If kindness were a drug, no doubt the Food and Drug Administration would approve it. Yet compassion is on the decline, and not just in medical care. Surveys have shown that contemporary polarized Americans value empathy less than they did a generation ago. The rise of corporate and bureaucratic processes in medical care, often exemplified through electronic medical record documentation requirements and productivity measures, have left many physicians feeling that their leaders do not value empathy either. Certainly, modern mass media portray physicians less as the kindly family doctor in Norman Rockwell’s portraits and more as the irascible Dr. House.
The declining emphasis on empathy may provide a clue to the solution. For if kindness is diminishing, it cannot be immutable or innate. Years of psychological research reveal that kindness is more like a muscle that one can exercise and build. For example, ancient meditative practices can build compassion, with demonstrable results on brain scans. While selecting more empathic medical students who will survive the well-known empathic drop during training should help, we can also design practices to support acts of kindness in medical care.
But how? One approach would be to changing the delivery system to encourage kindness. Many have pointed the finger at rising levels of bureaucratic processes in medicine as discouraging a more human touch. Tempting though it might be, resisting standardization and quality measurement is a fool’s errand. Not only are they deeply ensconced, they have proven benefits. Instead, a kinder delivery system might provide structures to support it. For example, Wu and colleagues at Johns Hopkins have designed and tested an on-call peer support system for providers. Fiction invites readers to take the characters’ points of view, and physician discussion groups build empathy, reduce burnout, and may even predispose kinder patient physician interactions. Enlightened delivery systems have sponsored similar programs.
In a more supportive environment, individual providers can also exercise their kindness muscles. It is probably too much to expect busy providers to develop a monastic devotion to loving kindness meditation. Instead, brief practices might suffice. Even a single 10-minute physician meditation session improved patient experience in a randomized trial. Just as importantly, it fostered self-compassion, which may be the most powerful antidote to provider burnout and forms the foundation for kind acts towards others.
Meditation is certainly not for everyone, yet other very practical techniques work as well. Just formalizing a kind intent improves subsequent kind acts in psychologic experiments. Perhaps rituals as simple as silently repeating that intent while handwashing before visits might be effective. During the patient encounter, giving providers straightforward scripts that communicate compassion—like “We will do and continue to do our very best for you”—had surprisingly long-lasting effects, again in randomized trials. While this may at first seem inauthentic, compassionate speech actually increases empathic feelings, setting up a virtuous positive feedback cycle towards more kind acts.
Given their potency, kindness interventions merit further serious investigation. But the strong existing evidence should propel us to learn more than just what techniques are most effective. How to spread those techniques is an even more pressing challenge in our modern frenetic delivery system. When asked, many providers cite lack of time as the main barrier. Yet compassionate communication need not take much longer—estimates are as low as 40 seconds per encounter. Implementation science can help guide investigation of the barriers and facilitators to kindness promoting interventions. Understanding these can transform what might seem a utopian goal into an implementable program.
In her book, The How of Happiness, psychologist Lyubomirsky lays out practical steps we can all take to lead happier lives, many of which are supported by randomized controlled trials. Indeed, one of the best supported practices for a happier life in the book is performing acts of kindness. In this polarized and pandemic-plagued era, we should ask how we, in medicine, can act as a balm. Zulman and colleagues (including SA) developed the Presence 5, simple practices to promote human-to-human connection in medical care specifically designed for pressured providers lives. If kindness is indeed at the heart of medical care, perhaps we need 5 more practices, the Kindness 5, that health care systems and providers could adopt and make the ghost of Donabedian proud. No doubt our troubled times would benefit from it.