Why kindness is the missing link in medical education [PODCAST]

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We welcome back internal medicine physician Vijay Rajput. Two years ago, he shared his insights on the KevinMD article, “Top 10 things new interns should do.” Today, he returns to discuss updates on those recommendations, with a new emphasis on empathy, compassion, and introducing the power of kindness in medical education and clinical practice.

Vijay Rajput is an internal medicine physician.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back VJ Rajput. He’s an internal medicine physician. He last came on a podcast talking about his article, “Top 10 things new interns should do.” We invite him back today to give an update on that article. VJ, welcome back to the show.

Vijay Rajput: Kevin, good morning, and thank you for having me. I really appreciate you giving me the opportunity to update or add some new information related to the article we published on your website as a blog.

Kevin Pho: All right. So we last spoke two years ago. Any changes in those two years in terms of your tips and advice on what new interns and residents should do to succeed?

Vijay Rajput: Yeah. So the last few years, I’ve been pondering this issue of empathy and compassion. Let me dive back. For the last twenty-five years, at least, in medical education and clinical health care, we’ve been telling physicians, students, and residents to show more empathy, and then we also moved to compassion. But I would like to introduce the concept of kindness. So if you give me a few minutes, I want to make clear to our audience the difference between sympathy, empathy, compassion, and kindness. So I will take a few minutes.

Sympathy is just you showing an individual superficial pity, right? I will just say, “Oh, sorry,” without having that feeling or even a cognitive response in my brain. A lot of the time, our students, or people any time they take a history, say, “Tell me about your family history.” “Oh, my parents died.” And my student will say, “Oh, sorry to hear that.” That “sorry” has no meaning to me. The only time people should use “sorry” in a health profession is if you made a mistake or an error, and a true apology should always have a “sorry.” So that’s sorry.

Empathy is really a conscious understanding, having an emotion or a response to somebody who is going through it, right? That’s a cognitive response, an emotional response, but that’s only left up to you. The word we have used is, right, to fill in someone’s shoes. That’s the word we commonly use. So that’s empathy. We’ve been teaching empathy. We’ve been assessing student empathy. We are saying, “Oh, they come with very great empathy in first year, and then by fourth year, they lose all the empathy.” We’ve been saying that.

Compassion, in a very simplistic mathematical way, is empathy plus action to alleviate somebody’s suffering. That’s compassion. In a very easy way, you have to have a desire, or at least an attempt, to alleviate somebody’s suffering. That’s compassion.

Now, kindness, that’s a very interesting one. We use the word kindness all the time, but kindness is any benevolent act or gesture where you want to respond to somebody with help, but that other person doesn’t have to be in distress and doesn’t have to be suffering through anything. So with kindness, first thing, you don’t need any emotional attachment with the person you’re going to show kindness to, and that person doesn’t have to be in a vulnerable situation. And we have a good number of people in health care and education, and we can show each other kindness, right? So I want to make a little bit of a shift in our education and in health care, so that maybe we can dive a little bit more into kindness.

And I can give you some examples, right? If you are an intern or a student walking in on the first day, or in your patient’s room, and a patient is ringing the bell looking for a urinal bottle, or my elderly patients in the old days couldn’t open the milk carton to pour the milk on the cereal on their breakfast tray, you help them out. You bring that urinal bottle. That’s kindness, right? You are not doing anything; they are not suffering distress. So there are a lot of opportunities we miss out on, and we don’t teach our students, residents, and faculty. So I’m really now pushing this as my mission: Let’s talk more about kindness. We should show compassion, there’s no question about it, because people were suffering and in distress, but let’s spread more kindness among each other.

Kevin Pho: So are you finding, in general, with the new residents and students that you see, that you have to teach kindness? It seems like it should be relatively innate. You gave that example of the patient ringing the bell and you giving them a urinal or whatever you need, just out of kindness. Does that need to be taught?

Vijay Rajput: You know, Kevin, that’s a good question. I used to think, yeah, we don’t need to teach that; they should have learned it, or they should know. But the answer is no. I think we need to, because I think in health care and in medical school, we give them a fixed job description, right? And they’ve been taught all these competencies now, and within a competency, they say, “Oh, breaking the bad news is one of your competencies,” or “You have this interpersonal communication.” Let me tell you, I’ve never seen the word kindness in there. I’ve seen the word empathy, and lately compassion.

So the answer is yeah. Even most of my residents will say, “Dr. Ashu, that’s not my job description. They are medical assistants. They are supposed to do it. They’re not doing their job.” And I say, “That’s not true. There are small gestures you can make any time to anybody within your profession, to the people surrounding you.” I think that elevates the whole level of engagement and well-being. I truly believe if you’re more kind, you are likely to get more engaged, you will reciprocate, and well-being also gets included.

Kevin Pho: So how do you go about teaching kindness to your students? Do you have a lecture? Do you do it through actions, and they model after you? How would you go about teaching your students kindness?

Vijay Rajput: You said the right word there: role modeling, Kevin. That’s the best way. I mean, I can throw a lecture. I have lately written a paper on bringing kindness into medical education. We need more role models, because if you don’t have a good role model, or you see people on the bad side, then they are much less likely to embrace it. So I’m completely with you. We need to teach them, advise and guide them, and tell them what kindness is. But at the end of the day, if you have more role models at every interprofessional level, in nursing, in the surgeon, and in the physician, that’s the best way.

And there are several examples, and students watch us. Trust me, they see us all the time. I still remember when I used to bring, and if I can diverge for one minute: Every time I was on a service, there was always one patient who might have a birthday coming up. Out of your fifteen patients in any hospital, I can tell you one or two patients have a birthday. I would just take out $20 and give it to my residents and students and say, “Hey, tomorrow we’re going to bring a cake from the cafeteria, or you can bring it from outside, and we’ll just go to the patient’s bedside.” Even if it’s a diabetic patient, we will bring the cake. “Dr. R, how do you want to bring the cake?” And we celebrate the birthday. It’s just a simple gesture, right?

Even I have given, many times, a couple of dollars to even my IV drug patient who said, “Doctor, I need a bus fare.” I will give her a couple of dollars. My residents will say, “Doctor, how do you know that he’s not going to use that money just to go buy drugs?” And I said, “I can’t worry about that, because in this moment, I have to trust that patient. I have to believe in this patient.” So yes, there are small gestures of kindness we can show each other at any level. I think that will help everybody in health care.

Kevin Pho: So tell me a story about how these gestures of kindness help patients. Give us a story about how that made an appreciable difference in a patient’s life.

Vijay Rajput: I will tell you, Kevin, all my career, every time I have shown kindness, even if I made a mistake with my patients, they will trust me. The best way of building trust with my patients is all about caring for them, caring with kindness, besides listening to them, and going the extra mile. And this is, I have a sort of thought pillar in my mind: going the extra mile for the people in front of you. That extra mile means this is not part of your job description.

I think this is a real problem in our country, community, and health care. Everybody says, “Oh, I have this job description. If I deviate from the job description, I might get in trouble.” And my answer is no. These are things where you just go the extra mile and help everybody surrounding you. And that also connects to the words practical wisdom. People talk about wisdom, but practical wisdom is deviating from the norm and helping the person in front of you. That’s practical wisdom. So that’s how I will say we should do more.

Kevin Pho: So let’s talk about role models, you and your fellow attending physicians. Sometimes it’s difficult to model kindness with all the frustrations, obstacles, and bureaucracy that you have to deal with. Sometimes kindness is lower down on the list. So how do you have that presence to demonstrate kindness on particularly bad days, when you’re undergoing a lot of stress, you have difficult patient encounters, you have difficult administrative encounters, and there’s so much more on your mind? How do you make room to think to yourself, “Hey, I also need to model kindness to my students as well”?

Vijay Rajput: Yeah, absolutely. So there are two things you have to do by the end of the day. Let’s say you behaved badly, and you realize that the incident did not go well with a patient or a nurse, because you were in that moment. We are all human beings and likely to get stressed out. If you have that situation, two things have to happen. The person you have shown your microaggression, micro-incivility, or micro-, they need some sort of apology, or at least for you to say, “You know, I put you in this situation. My apology.” That has to happen. And second, the people who are observing you, and you are the role model, require at least five or ten minutes of debriefing at the end of the day, where you say, “What do you think happened in that incident when we went into this patient’s room? What do you think I did?” And you have to have that ease, and at least the guts, to tell your learners, and not to feel, “Oh, how am I going to look now? Because they’re going to say Dr. Raj is not good.” No, actually, you will get elevated.

So I’ve done that if I went and did something wrong. I’ll give you an example. Recently, this happened in a Zoom meeting with somebody we were interviewing as five faculty members. One of my faculty members asked a question which, truly, in any book, could have been seen as a microaggression. The interviewer really sensed it, but he or she did not respond. I needed to set up another meeting, debrief my faculty, and say, “What happened here?” And I had to tell my other people. So at the end of the day, you need to close that incident, because that’s the only way the learner will learn and say, “Oh, I really realize that that has happened.” And I think they will role model the same thing.

Kevin Pho: And I’m assuming that should happen on the same day.

Vijay Rajput: It should not happen after a week, because then people will forget.

Kevin Pho: So you mentioned earlier, when you mentioned mentoring and teaching new students and residents, that you have formal courses on empathy, or you said that empathy can be taught. So in your program, and within the academic medical education community, how does one teach empathy to new students and residents?

Vijay Rajput: So with empathy, going back to whether it’s nature or nurture, my feeling is it’s both. You need to have a small basic substrate within you. I cannot fully, suddenly say, “Kevin, here is a script; you are an empathetic physician up front now.” But if they have the basic stuff, then you can build on it, and the building can happen in every format and every way. I mean, nowadays we do it through standardized patients in early education across the medical school. Then you really want to make sure the near-peer learning also shows the same empathy, so the interns, residents, and fellows. If that happens, then you bring it in as part of the discussion. I think a lot of debriefing and reflection is the important part of learning empathy and compassion. Without that, I don’t think we can learn it just by reading books.

Kevin Pho: So as I said earlier, we last spoke about two years ago. You were giving a similar topic on this podcast, tips new interns should do. So how have these new interns been over the last few years? Have you noticed any trends among the new medical residents that you’re seeing today?

Vijay Rajput: So I think the challenge we are having right now in the discussion at the national level, and you are very much aware, is about burnout and well-being. We are all worried about their early burnout in their internship and residency. And I think the challenge is two things. We do not engage them fully in providing psychological safety, right? And psychological safety to handle the difficult, stressful situations, the ones which I will describe.

They need to learn how to manage three M’s early on, or during the residency, as I call them. One is micromanagement. They want autonomy as they become interns and residents, but you and I know there are physicians who just do not have the capability to provide enough freedom or autonomy to the resident, and they keep on hovering around and micromanaging. When I was a program director, every time a resident would say, “Doctor, how can you make this faculty micromanage me less? I’m doing a great job.” Very difficult, very difficult. And sometimes it’s very easy for a micromanaging supervising physician to say, “VJ, I was doing it for patient safety and a quality indicator,” right? An easy way. So that’s the one. I need to help them, and we need to help them navigate the micromanaging supervisor.

The microaggression part: The reason microaggression and micro-incivility never rise to intervention by leadership or at the organizational level is that they are very subtle. They’re almost inconsequential and inconsiderate small, small behaviors. And all three of these are in the eye of the beholder, right? It is always in the eye of the beholder. The residents, the students, and younger faculty can perceive it, but the person who is doing it usually doesn’t even recognize it, or doesn’t have the insight that he’s proclaiming all three of these behaviors.

So what we need is a dialog, and to train our early interns and residents that they are going to come across them. It is very difficult to say we are going to eradicate them. I would be naive if I said we will be able to eradicate micromanagement, microaggression, and micro-incivility. But we need to prepare our learners for how to handle that. And I think we should also help our younger physicians with how they can overcome it and not show these three behaviors, as I call them, which many times are only in the eye of the beholder.

Kevin Pho: And do you have any sessions that can help new interns manage those three M’s?

Vijay Rajput: So it’s very early. I have come up with this, so we are putting it through some workshops at the national level for educators, so it becomes part of faculty development. A lot of people have been teaching microaggression. It has been taught for the last ten years; the paper first came from Columbia. Christine Porath has written a book on incivility in health care and any organization. So there’s a lot of discussion there, but it has not been put together in medical education. I’m hoping that in the next few years, I will have some more research and more faculty development, and disseminate this so learners understand how to navigate it and faculty learn how to mitigate their own behavior.

Kevin Pho: And you mentioned burnout, especially in early-career physicians. What do your program or other medical educators do to help mitigate early burnout? Because, as you know, burnout is prevalent throughout medical education and throughout the careers of physicians. What are some ways that we can mitigate that early on?

Vijay Rajput: So I think what we all do, which everybody is doing, is we can all do meditation, yoga, exercise, and healthy eating and habits. But my personal belief is the only way we can prevent burnout and avoid burnout is meaningful engagement with your patients and finding the joy in taking care of the patient. If you don’t, and also, we need to role model the joy of taking care of the patient, because if you don’t find the joy in what you’re doing, it doesn’t matter what we do and help them with the other parts of the world or the other parts of their life. They will still feel the burnout. That’s difficult because, as you just discussed, there are stressful situations, there are stressful days, and there are stressful patients. But we all need to, at the end of the day, find that joy in taking care of the patient. We can at least mitigate or prevent the burnout.

Kevin Pho: We’re talking to VJ Rajput. He’s an internal medicine physician, and we’re following up on his KevinMD article, “Top 10 things new interns should do.” This is an update podcast on something he came on the show for two years ago. VJ, we’ll end with some of your take-home messages for the KevinMD audience.

Vijay Rajput: So my take-home message, Kevin: We should now talk about kindness along with compassion and empathy when we talk about empathy and compassion in education and clinical care, and disseminate and find the way and the opportunity to show kindness to each other. And I would also like to find a way to manage these three M’s, which I call micromanagement, microaggression, and micro-incivility, and prepare our young learners, our early learners, for how to navigate them, and the faculty and the clinicians should learn how to mitigate or diminish them in their behavior in the day-to-day workplace. And I think that will be my message. That will help to prevent burnout, and we will all at least enhance our well-being. And at the end of the day, our patients also benefit in a big way.

Kevin Pho: VJ, thank you so much for coming on the show again and sharing your time, insight, and perspective.

Vijay Rajput: Kevin, thank you for having me, and have a good day.

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