A journey from shame to kindness
Nice doctors don’t get sued, goes the saying. Studies show that just10 per cent of patients who have a case for malpractice sue their doctor. And when they make the difficult decision to take them to court, the most influential factor is seldom competence. It’s usually about lack of communication and of caring.
When a patient or a family member calls the doctor incompetent, he or she can brush it off. That’s because it’s rare to find a layperson who understands the difference between clinical skill and a good bedside manner.
But when they call you unkind, they know what they’re talking about.
Years ago, I saw an elderly woman in the emergency department who was in the advanced stage of a degenerative disease. The family had brought her to the emergency department because they felt they could no longer care for her at home.
There was no compelling medical reason for her to be admitted to the hospital. I found that she had been looked after well. She had no acute medical issues that required immediate admission to hospital. She was thin, though well-nourished on a pureed diet. She wasn’t dehydrated. She didn’t have pneumonia, and she didn’t have a fever.
Still the family members were at the end of their rope. At the time, I did not see that. In the moment, I saw their insistence that she be admitted as demanding and pushy. I did what they asked, but I did so in a begrudging way. I was unkind to them. At one point, one of the family members asked if I had done the referral and I snapped at this person.
The internist on call admitted the woman to the hospital, and I moved on to seeing other patients in the ER. A few weeks later, the woman passed away.
A few months later, the woman’s husband wrote me a letter in which he told me flat-out that I had been unkind to him and to his family. He asked me to meet with his family because he wanted to see if a kind soul lurked under that abrupt demeanour.
I thought about meeting the family with an adviser. My Chief offered to accompany me for moral support. Even though I knew my competence was not in question, I still felt worried enough to consider his offer. But I ended up attending the meeting alone.
It was not an easy session. The husband came along with all of their adult children along with their spouses. Each took a turn speaking, giving me a vivid picture of a vibrant and accomplished woman, a loving partner and a devoted mother and grandmother. Their words touched me so much that I found myself crying, as did they.
Their love and tenderness became real and important to me because I slowed down long enough to listen. Years later, as I sat at the hospital bedside of my ailing parents, I gained an even greater understanding of where that family was coming from.
The meeting made me feel something else. Shame. I was ashamed of how I had behaved with the family during the hurried encounter in the ER.
It turns out that I’m not alone. In powerful commentary published in 2017, in the British Medical Journal, Luna Dolezal and Barry Lyons argued convincingly that shame is “underacknowledged, under-researched and undertheorized in the contexts of health and medicine.” They go on to describe the maladaptive things health professionals do to deal with shame, including what they referred to as “acute shame avoidance behaviour.” By that, the authors meant denying accusations of unkindness, rationalizing bad behaviour and blaming others.
Like many health professionals, when I make a mistake or get called out for bad behaviour, I feel shame deep within my bones. Shame is very different from guilt. When you feel guilty about something, you are motivated to learn from it and to repair the damage. When you feel shame, you avoid revisiting what happened because it confirms that you are a person beyond redemption.
Like many health professionals, I probably became a physician to try and do good deeds to compensate for that pervasive feeling.
Since my journey to learn about kindness, I have come to realize that when I was speaking with the family in the ER, their “pushiness” made me feel defensive. I was preoccupied with fending off accusations of everything from incompetence to an inability to summon the internist to admit the woman on the spot.
In other words, during my encounter with the woman and her family, I was thinking of my own distress, not theirs.
Cognitive empathy is defined as the capacity to imagine what it’s like to be another person, and to let that picture govern one’s actions toward that person.
Health professionals who feel shame find it painful to imagine what it’s like to be a patient or a family member because they imagine the patient or the family member judging them harshly.
Shame kills empathy. But talking about the things one is ashamed of takes the sting out of being judged, and allows empathy to flourish.
That family took the sting out of my shame, and while making it clear that they saw me as a fellow human being despite my faults.
That story set me on a voyage to learn about kindness and empathy, and to try and rediscover it within me.
But the lesson that family gave me, more than any other, told me that deep down inside, I was still hard-wired to be kind.