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Compassion and the science of kindness: Harvard Davis Lecture 2015

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Abstract

The Francis Report1 was unequivocal in its findings. The Mid Staffordshire Trust had allowed the following to happen: ‘ Patients were left in excrement in soiled bed clothes for lengthy periods ’ and ‘ Water was left out of reach’. Robert Francis observed that: ‘ Staff treated patients and those close to them with what appeared to be callous indifference. ’ And, in conclusion, he wrote that: ‘ Patients must be the first priority in all of what the NHS does … (and) receive effective care from caring, compassionate and committed staff, working within a common culture. ’ 1 What went on in the Mid Staffs Trust is a chilling indictment of what happens when we lose sight of the importance of kindness when caring for our patients. This lecture is about the importance of kindness in the consultation and in our relationships with others. It is based on a lecture given to RCGP Wales and is a brief synopsis of its content. Unfortunately, space does not permit a detailed examination of the key themes of the lecture. Interested readers are, therefore, invited to read the full text through the link at the end of this paper. In summary, my main contentions are that it is kindness which makes us human , builds resilience, and makes us better doctors and better people. Although we may not be sure exactly what kindness is, we can all recognise it when we see it! Indeed, it is often the case than nothing upsets us more than when someone is being deliberately unkind to us or others. How to define kindness? Cole-King and Gilbert have defined compassion (or kindness) as being ‘ sensitivity to the distress of … others with a commitment to try and do something about it’. 2 The key point …
INTRODUCTION
The Francis Report1 was unequivocal in its
findings. The Mid Staffordshire Trust had
allowed the following to happen:
‘Patients were left in excrement in soiled
bed clothes for lengthy periods’
and
‘Water
was left out of reach’.
Robert Francis observed that:
‘Staff treated patients and those close to
them with what appeared to be callous
indifference.’
And, in conclusion, he wrote that:
‘Patients must be the first priority in all of what
the NHS does
(and)
receive effective care
from caring, compassionate and committed
staff, working within a common culture.’
1
What went on in the Mid Staffs Trust is a
chilling indictment of what happens when
we lose sight of the importance of kindness
when caring for our patients.
This lecture is about the importance of
kindness in the consultation and in our
relationships with others. It is based on a
lecture given to RCGP Wales and is a brief
synopsis of its content. Unfortunately, space
does not permit a detailed examination of
the key themes of the lecture. Interested
readers are, therefore, invited to read the
full text through the link at the end of this
paper. In summary, my main contentions
are that it is
kindness which makes us
human
, builds resilience, and makes us
better doctors and better people.
DEFINITIONS
Although we may not be sure exactly
what kindness is, we can all recognise it
when we see it! Indeed, it is often the case
than nothing upsets us more than when
someone is being deliberately unkind to us
or others. How to define kindness?
Cole-King and Gilbert have defined
compassion (or kindness) as being
‘sensitivity to the distress of … others with a
commitment to try and do something about
it’.
2 The key point here is that, if we are to be
kind, then not only do we need to be sensitive
to the suffering of others, but we also need
to make a constructive response in such
circumstances. Kindness requires action.
Kindness, therefore, is not an ‘optional
extra’ only to be deployed when we have
sufficient time and energy, nor should it be
instrumental in achieving another purpose
such as meeting targets. Kindness should
be central to our engagement with others
(for example, in the consultation) because it
is central to healing.
The RCGP motto is
Cum Scientia
Caritas
scientific knowledge applied with
compassion.
Caritas
will be defined here
as the open-heartedness or generosity of
spirit demonstrated by a doctor or nurse
when caring for a patient. It will be used
synonymously with kindness, compassion,
altruism, and generosity because space does
not permit a more detailed exploration here.
HISTORICAL PERSPECTIVES
The origins of kindness lie in ‘kinship’ but
over the centuries its meaning and purpose
have been expressed in different ways. In
the Victorian era, for example, kindness
became feminised and synonymous with
sentimentality.3 The Victorian housewife
became
The Angel in the House
4 and men
feared that too much sympathy might erode
their gravitas and cloud their thinking on
important matters!
Darwin, in
The Descent of Man
, was clear
that sympathy and cooperation were innate
and key to evolutionary success5 and although
Dawkins in
The Selfish Gene
described
the ‘
gene’s law of universal ruthlessness
and selfishness’
,6 he emphasised also the
crucial importance of teaching our children
both generosity and altruism.
Freud described all kindness as seduction7
and argued that it is therefore only exercised
for unconscious (or conscious) ulterior
motives for a specific purpose.
However, I believe that altruism remains
alive and well in our society. Richard Titmuss,
for example, in his classic study
The Gift
Relationship
reported that more than 98%
of blood donors give blood for someone
they have never met, nor indeed are ever
likely to meet.8 The NHS itself, of course, is
founded on great altruistic principles: the
idea that through collective provision high-
quality health care can be delivered to those
who most need it, even though we will never
meet those most in need of that care.
Despite all of its problems, the NHS is still
loved and valued by the majority of people in
this country who recognise its fundamental
altruistic importance to our society.
THE NEUROSCIENCE OF KINDNESS
Ballatt and Campling in their 2011 book,
Intelligent Kindness: Reforming the Culture
of Healthcare
,9 summarise some of the
evidence for the impact that kindness can
have on our own brains.9
For example, in altruistic individuals,
increased activity in the posterior superior
temporal cortex has been reported (when
compared with less altruistic individuals).
Individual acts of kindness release both
endorphins and oxytocin, and create new
neural connections. The implications for
such plasticity of the brain are that altruism
and kindness become self-authenticating.
In other words, kindness can become
a self-reinforcing habit requiring less and
less effort to exercise. Indeed, data from
functional magnetic resonance (FMR)
scans show that even the act of
imagining
compassion and kindness activates the
soothing and affiliation component of the
emotional regulation system of the brain.10
There is also some evidence to link the
importance of kindness with healing, and the
impact of the quality of the interaction between
a health professional and a patient on the
placebo effect
is well recognised. There are
also claims of improved diagnostic accuracy
associated with empathic staff — as well as
an observed effect of kindness on promoting
healing and reducing anxiety. In a randomised
controlled trial of ‘compassionate care’ for
the homeless in an emergency department,
frequent attenders received either ‘usual
care’ or a compassionate care ‘package’.
The outcomes included fewer repeat visits
and increased satisfaction with their care in
the intervention group.11
Compassion and the science of kindness:
Harvard Davis Lecture 2015
Debate & Analysis
“Kindness … is not an ‘optional extra’ only to be
deployed when we have sufficient time and energy,
nor should it be instrumental in achieving another
purpose such as meeting targets.”
e525 British Journal of General Practice, July 2016
KINDNESS AND WORKLOAD
It is generally agreed that our current
workload in general practice is not only
unsustainable but also gradually increasing.
More than 15 million of us already have
long-term conditions and these account for
some 70% of the NHS spend and more than
50% of all our consultations as GPs.12
If we are to address the current workload
crisis, we need to find new ways of working
and the Five Year Forward View (Vanguards
programme) provides us with opportunities
to do this.13 Central to the Vanguards
programme is the idea of person-centred
care14 and it is my view that our most
underutilised and indeed our greatest
resource is the desire and willingness of
our patients to contribute to their
own
care.
One of the key aspects of care that
patients most value is that of kindness
(compassion) in the consultation.
However, the introduction of the Quality
and Outcomes Framework (QOF) and the
resultant emphasis on the biomedical
aspects of care have made it more difficult
for us to practise ‘holistic’ care and engage
with our patients in a compassionate way.
For example, Carolyn Chew-Graham and
colleagues showed that the use of QOF
patient templates during the consultation
makes holistic engagement with patients
more difficult.15
In the current workload crisis do we have
time for kindness?
With the rapid increase in the numbers
of people with long-term conditions
and the importance of supporting self-
management, I wish to argue that
we cannot afford
not
to be kind in the
consultation. Being kind is what to do when
‘working harder isn’t working’.16 It may
sound counterintuitive but, actually, taking
the time to be kind by engaging our patients
more fully in their own care, can reduce our
workload and increase our resilience. This
is because our individual acts of kindness
will be reciprocated by our patients,
strengthening our relationship with them
and improving our own wellbeing.
I believe that kindness is good for us
as well as our patients, and, furthermore,
kindness builds our resilience.
KINDNESS: A VIRTUOUS CYCLE
If kindness is such an important component
of care, can it be taught? Gilbert has
described some of the attributes and
skills for compassion that are necessary
for the provision of compassionate care.17
The necessary attributes include sympathy,
distress tolerance, empathy, and non-
judgement, coupled with a sensitivity and care
for wellbeing. Such attributes are necessary
for engagement of others, and, once engaged
with others, the skills of imagery, reasoning,
and attention are all required.
Kindness cannot be faked — most of
us will be familiar with the insincerity of
the brief professional ‘half-smile’ of
overworked air cabin crew, and how such
insincerity undermines the trust necessary
for ‘real’ kindness to be both expressed
and meaningful to our patients. However,
although we can identify some of the skills
and attributes necessary for the expression
of kindness, it is
attitudinal
change that is a
prerequisite for the expression of kindness
in the consultation; in other words, despite
the efforts of some NHS management,
kindness cannot be mandated.
Ballatt and Campling describe a
virtuous
cycle of kindness
whereby kindness directs
attentiveness
, which in turn enables
attunement
, which builds trust between
ourselves and our patients.9 This trust
generates a
therapeutic alliance
that
produces better outcomes for patients. As
it turns, this virtuous cycle can reduce
anxiety and defensiveness, and reinforce
the conditions for kindness to take place.
Such cycles not only can improve the care
of our patients but they also can reduce
our own stress and improve our morale in
the face of overwhelming demand. These
virtuous cycles are the polar opposite of
the ‘downward spiral’ that can arise from
‘burnout’ and overwork, in turn leading to
poor morale and loss of confidence and
belief in what we are doing.
Why is kindness important?
‘Kindness
(compassion)
is a gift freely given
by one person to another in the health
service — just like anywhere else.’
18
Chadwick’s definition above is a good
one — it gives us a pragmatic definition to
underpin our care of patients. In addition,
thinking of kindness as a ‘gift freely given’
often chimes with our original motivation
to become doctors — that is, the desire to
help and look after others. And most of us
would agree that
‘kindness encourages a
feeling of aliveness and creates the kind of
intimacy and involvement with other people
that deep down we crave’.
3
Kindness is important for both ourselves
and our patients. The Schwartz Centre for
Compassionate Healthcare in Boston is
named after Kenneth Schwartz, who was a
healthcare lawyer with a young family who
died at the age of 40 from lung cancer. He
described the ordeal of his treatment as
being
‘punctuated by moments of exquisite
compassion’
and how the
‘simple human
touch from his care givers made the
unbearable bearable’.
19
I believe this should resonate for all of
us whether we are the recipient of acts
of kindness or the person offering this
gift to others. I leave you with the words
of Hippocrates who knew full well the
importance of kindness (comfort) when
caring for our patients. He famously said
that as doctors we should:
‘Cure sometimes, treat often, and comfort
always.’
Nigel Mathers,
RCGP Honorary Secretary and Professor of Primary
Medical Care, University of Sheffield, Sheffield.
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The author has declared no competing interests.
This is an abridged version of the Harvard Davis
Lecture delivered to RCGP Wales in Llandudno on
12 November 2015. The full text can be accessed at
http://www.sheffield.ac.uk/medicine/research/aupmc.
ADDRESS FOR CORRESPONDENCE
Nigel Mathers
Head of Academic Unit of Primary Medical
Care, University of Sheffield, Samuel Fox House,
Northern General Hospital, Herries Road, Sheffield,
S5 7AU, UK.
E-mail: n.mathers@sheffield.ac.uk
“… taking the time to be kind by engaging our patients
more fully in their own care, can reduce our workload
and increase our resilience.”
British Journal of General Practice, July 2016 e526
©British Journal of General Practice
This is the full-length article (published online
1 Jul 2016) of an abridged version published in
print. Cite this article as: Br J Gen Pract 2016;
DOI: 10.3399/bjgp16X686041
e527 British Journal of General Practice, July 2016
homeless in an emergency department.
Lancet
1995; 345(8958): 1131–1134.
12. Ipsos MORI.
Long term health conditions
2011: research study conducted for the
Department of Health
. 2011. https://www.
gov.uk/government/uploads/system/uploads/
attachment_data/file/215340/dh_130806.pdf
(accessed 31 May 2016)
13. NHS.
Five year forward view
. 2014.
https://www.england.nhs.uk/wp-content/
uploads/2014/10/5yfv-web.pdf (accessed 31
May 2016).
14. NHS, Year of Care Partnerships. Meet the
team. http://yearofcare.co.uk/meet-team
(accessed 31 May 2016).
15. Chew-Graham CA, Hunter C, Langer S,
et
al
. How QOF is shaping primary care review
consultations: a longitudinal qualitative study.
BMC Fam Pract
2013; 14: 103.
16. O’Hara B.
Working harder isn’t working: how
we can save the environment, the economy,
and our sanity by working less and enjoying life
more.
Vancouver: New Star Books, 1993.
17. Gilbert P.
The compassionate mind.
London:
Robinson, 2009.
18. Chadwick R. Compassion: hard to define,
impossible to mandate.
BMJ
2015; 351: DOI:
10.1136/bmj.h3991.
19. Schwartz KB. A patient’s story.
Boston Globe
Magazine
;
16 Jul 1995. Reprinted courtesy of
the Kenneth B. Schwartz Center. http://www.
theschwartzcenter.org/media/patient_story.pdf
(accessed 31 May 2016).
REFERENCES
1. Francis R.
Report of the Mid Staffordshire
NHS Foundation Trust public inquiry:
executive summary
. 2013. https://www.gov.
uk/government/uploads/system/uploads/
attachment_data/file/279124/0947.pdf
(accessed 31 May 2016).
2. Cole-King A, Gilbert P. Compassionate
care: the theory and the reality.
J Holistic
Healthcare
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connectingwithpeople.org/sites/default/
files/Compassionate%20care%20ACK%20
and%20PG.pdf (accessed 31 May 2016).
3. Phillips A, Taylor B.
On kindness.
London:
Penguin, 2009.
4. Patmore C.
The angel in the house.
http://
academic.brooklyn.cuny.edu/english/melani/
novel_19c/thackeray/angel.html (accessed 31
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5. Darwin C.
The descent of man: selection in
relation to sex.
London: Penguin, 2004.
6. Dawkins R.
The selfish gene
. 30th anniversary
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7. Storr A.
Freud: a very short introduction
. New
edn. Oxford: Oxford University Press, 2001.
8. Titmuss RM.
The gift relationship: from human
blood to social policy
. Exp. sub. edn New York:
New Press, 1977.
9. Ballatt J, Campling P.
Intelligent kindness:
reforming the culture of healthcare.
London:
RCPsych Publications, 2011.
10. Gilbert P, Choden.
Mindful compassion.
London: Robinson, 2013.
11. Rendelmeier DA, Molin J, Tibshirani RJ. A
randomised trial of compassionate care for the
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Long-term conditions (LTCs) are increasingly important determinants of quality of life and healthcare costs in populations worldwide. The Chronic Care Model and the NHS and Social Care Long Term Conditions Model highlight the use of consultations where patients are invited to attend a consultation with a primary care clinician (practice nurse or GP) to complete a review of the management of the LTC. We report a qualitative study in which we focus on the ways in which QOF (Quality and Outcomes Framework) shapes routine review consultations, and highlight the tensions exposed between patient-centred consulting and QOF-informed LTC management. A longitudinal qualitative study. We audio-recorded consultations of primary care practitioners with patients with LTCs. We then interviewed both patients and practitioners using tape-assisted recall. Patient participants were followed for three months during which the research team made weekly contact and invited them to complete weekly logs about their health service use. A second interview at three months was conducted with patients. Analysis of the data sets used an integrative framework approach. Practitioners view consultations as a means of 'surveillance' of patients. Patients present themselves, often passively, to the practitioner for scrutiny, but leave the consultation with unmet biomedical, informational and emotional needs. Patients perceived review consultations as insignificant and irrelevant to the daily management of their LTC and future healthcare needs. Two deviant cases, where the requirements of the 'review' were subsumed to meet the patient's needs, focused on cancer and bereavement. Routine review consultations in primary care focus on the biomedical agenda set by QOF where the practitioner is the expert, and the patient agenda unheard. Review consultations shape patients' expectations of future care and socialize patients into becoming passive subjects of 'surveillance'. Patient needs outside the narrow protocol of the review are made invisible by the process of review except in extreme cases such as anticipating death and bereavement. We suggest how these constraints might be overcome.
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Freud: A Very Short Introduction discusses the life and work of Sigmund Freud. The founder of psychoanalysis, Freud developed a totally new way of looking at human nature. Only now, with the hindsight of the half-century since his death, can we assess his true legacy to current thought. This VSI offers a lucid and objective look at Freud's major theories, evaluating whether they have stood the test of time. In the process it also examines Freud's family life, personal traits, and correspondence with contemporaries, assessing him in light of his own ideas.
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Este trabajo se presentó en una reunión científica de OPUS el 19 de enero de 2012 en Londres. Tomando ideas del libro del mismo título, explora las condiciones que facilitan o impiden la compasión en la asistencia en salud mental y en las organizaciones que la administran. Ballatt y Campling argumentan que el SNS es un sistema que invita a la sociedad a valorar y satisfacer al máximo intereses comunes: una expresión vital de comunidad que pueda mejorar si la sociedad, los pacientes y el personal pueden reconectarse con estos valores profundos. Las crueles "reformas" reguladoras y estructurales han fracasado en el intento de evitar escándalos, permitiendo que el personal de los servicios de salud mental se sienta alienado. Las aproximaciones industriales y comerciales a la reforma, méritos aparte, necesitan urgentemente equilibrarse por medio de una comprensión aplicada de lo que promueve y garantiza una práctica compasiva. Dada la historia reciente de preocupación y ansiedad, y la amenaza de más cambios por la reorganización del National Health Service (NHS), plantean que esta perspectiva resulta más crítica que nunca.
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Introduction The nature of the following work will be best understood by a brief account of how it came to be written. During many years I collected notes on the origin or descent of man, without any intention of publishing on the subject, but...
Article
In the current resurgence of interest in the biological basis of animal behavior and social organization, the ideas and questions pursued by Charles Darwin remain fresh and insightful. This is especially true of The Descent of Man and Selection in Relation to Sex, Darwin's second most important work. This edition is a facsimile reprint of the first printing of the first edition (1871), not previously available in paperback. The work is divided into two parts. Part One marshals behavioral and morphological evidence to argue that humans evolved from other animals. Darwin shoes that human mental and emotional capacities, far from making human beings unique, are evidence of an animal origin and evolutionary development. Part Two is an extended discussion of the differences between the sexes of many species and how they arose as a result of selection. Here Darwin lays the foundation for much contemporary research by arguing that many characteristics of animals have evolved not in response to the selective pressures exerted by their physical and biological environment, but rather to confer an advantage in sexual competition. These two themes are drawn together in two final chapters on the role of sexual selection in humans. In their Introduction, Professors Bonner and May discuss the place of The Descent in its own time and relation to current work in biology and other disciplines.