{"id":31851,"date":"2014-07-01T12:40:09","date_gmt":"2014-07-01T11:40:09","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=31851"},"modified":"2014-07-28T16:32:48","modified_gmt":"2014-07-28T15:32:48","slug":"neal-maskrey-the-importance-of-kindness","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2014\/07\/01\/neal-maskrey-the-importance-of-kindness\/","title":{"rendered":"Neal Maskrey: The importance of kindness"},"content":{"rendered":"

\"neal_maskrey\"<\/a>We seem to have a little hit on our hands. The BMJ<\/em> published our Analysis article\u00a0\u201cEvidence based medicine: a movement in crisis?<\/a>\u201d and within a few days, the social media channels were humming. Returning to the original concept of EBM, which was all about the holistic care of individual patients, seems to have struck a chord not just with us, the authors of the paper, but with readers too. One of the rapid responses said: \u201cThis article describes the sort of medicine I aspire to practice.\u201d Aspire to. What a phrase. And in an instant I\u2019m back in the surgery, and thinking about all those times I wished it had gone better.<\/p>\n

Not that it was terrible. In many ways, my time of practising was a golden age, with increasing and better services for patients, the introduction of chronic disease registers, proper screening and vaccination programmes, expanded premises, electronic medical records, GP training, and so on. We even managed the odd bit of decent medicine; the parathyroid adenoma diagnosis lives with me decades later.<\/p>\n

Twenty\u00a0years on, repeat requests from old colleagues and their successors for more nagging (cunningly disguised as decision making and EBM workshops) are the greatest compliment. But thinking back, the rapid responder had it. With the best of intentions and in a search for clinical excellence, I sometimes lost sight of the big picture. The one thing I regret is\u2014and it was hidden in plain sight all around\u2014I wish I\u2019d recognised the importance of kindness.<\/p>\n

In my defence, I was sleep deprived to a dangerous degree. In those days we did our own on call, and with three young children who were all terrible sleepers, much of my 30s is a blank. Music, films, books\u2014all were strangers to me. Daytime demands increased inexorably too. I\u2019m hopeless in a 1980s pub quiz.<\/p>\n

And it wasn\u2019t just me. When we eventually set up an out of hours cooperative, I got letters from spouses saying: \u201cThank you so much, you\u2019ve given me my husband back.\u201d Gulp. We now know that after a night on call our affective biases<\/a> kick in and our risk of making an error goes up. Shifts and loss of continuity are of course far from perfect, but I\u2019ll be on the barricades if working a day, a night, and the next day are ever back on the cards.<\/p>\n

So, back to kindness. Since we started working on the paper, I\u2019ve discovered a couple of genius American writers: George Saunders<\/a> (GS) and David Foster Wallace<\/a> (DFW). I\u2019ve not yet found them covering medicine per se, but they both cover some of the big questions in medicine. GS\u00a0gets it: \u201cWhat I regret most in my life are failures of kindness. Those moments when another human being was there, in front of me, suffering, and I responded . . . sensibly. It\u2019s a little facile, maybe, and certainly hard to implement, but I\u2019d say, as a goal in life you could do worse than: Try to be kinder.\u201d<\/p>\n

Think back to those times when you were ill or troubled. I bet the bits that you remember are the kindnesses and, yes, the times when kindness was absent. How we deliver care matters, as well as the outcome. I guarantee I never set out for the surgery vowing: \u201cToday, I\u2019ll be unkind,\u201d and neither\u00a0do you. Why do we sometimes lose focus? There has to be more to it, and indeed there is.<\/p>\n

Knowing about ourselves and our own reactions helps us understand more often what\u2019s going on around us. For we are, as far as we are concerned, the centre of the universe. Everything we see happens to us, and cognitively the default reaction is literally it’s \u201call about me\u201d\u2014if we\u2019re not careful. If we think about it consciously, even briefly, of course we know better, but instinctively we aim to self-preserve, and we see reinforcing self-preservation going on all around us as our colleagues also struggle with work and their own lives of quiet desperation.<\/p>\n

Don\u2019t think I\u2019ve gone soft over the years and forgotten the bone aching, brain dead days (and there were many of them), when I should have been the GP wearing lycra and trainers as I ran, literally, from one patient with complex, unsolvable, and distressing problems to the next . . . \u00a0and the next . . . and the next. But under that pressure it\u2019s all too easy, because of how we are hardwired, for it to become about me. We can forget that, actually, it\u2019s all about them and we have a choice.<\/p>\n

As I write this, I\u2019m irritated by the woman next to me on the train, who is crowding my personal space and playing her music too loudly. I could easily get cross and grumpy, because of course it\u2019s all about me. But there is another explanation, perhaps. It\u2019s likely she isn\u2019t doing that to be unpleasant. Maybe she\u2019s had a bad time at work today and is preoccupied with that, or she\u2019s going home to be a carer for her Mum who\u2019s ill, or . . . and then, once we start to think about them rather than me, there are a thousand other more plausible explanations than \u201cit’s about me.\u201d<\/p>\n

No one should expect, or be expected, to automatically feel differently about what they feel. Our default settings are just that\u2014our default. DFW, writing about all this, says: \u201cIt\u2019s hard, it takes will and mental effort, and if you\u2019re like me some days you won\u2019t be able to do it, or you just flat-out won\u2019t want to. But most days, if you give yourself a choice, you can choose to look differently.\u201d I\u2019m trying David, every day I\u2019m trying.<\/p>\n

GS reckons that as we age it gets easier\u2014we naturally become kinder. Big things happen to us, we start to see better what really matters, and what, on the other hand, is at worst a passing irritation. In our own dark, tender moments<\/a> we receive care with compassion ourselves, and the importance of kindness becomes more obvious. And especially, once the sleep deprivation wears off, we see the unselfishness that comes from having children and grandchildren. Those of you in that happy position know that it isn\u2019t about you any more, it\u2019s about them. If you don\u2019t feel it yet, you will. Ask any parent or grandparent. \u201cAs long as the kids are ok.\u201d<\/p>\n

Of course we must take our clinical expertise seriously, finding (not knowing) the best evidence, and our many other doctoring roles. These are incredibly important, not just for our patients, but also for the people we work with so our teams and organisations get along as best they can. But if we worship the god of having to know all of the evidence, and think that\u2019s the most important thing, then we ourselves will struggle.<\/p>\n

As DFW says: \u201cThe really important kind of freedom involves attention, and awareness, and discipline, and effort, and being able to truly care about other people and to sacrifice for them, over and over, in myriad petty little unsexy ways, every day . . . The alternative is unconsciousness, the default setting, the \u201crat race\u201d\u2014the constant gnawing sense of having had and lost some infinite thing.\u201d<\/p>\n

If George is right that over time we\u2019re going to get kinder anyway, let\u2019s \u201churry up, speed it along, start right now.\u201d It won\u2019t be easy, but it\u2019s the sort of medicine I aspired to practice.<\/p>\n

Neal Maskrey’s<\/strong>\u00a0early career was as a GP before spending seven years as a medical manager and part time GP. After 12 years as a director of the National Prescribing Centre and programme director at NICE, he is now honorary professor of evidence-informed decision making at Keele University, and consultant clinical adviser in the Medicines and Prescribing Centre, NICE.<\/em><\/p>\n

Competing interests: I declare that I have read and understood the BMJ Group policy on declaration of interests and I hereby declare the following interest: Employed part time by the National Institute for Health and Care Excellence.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

We seem to have a little hit on our hands. The BMJ published our Analysis article\u00a0\u201cEvidence based medicine: a movement in crisis?\u201d and within a few days, the social media […]<\/p>\n

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