Systemic unkindness? (18.08.2017)
A few years ago, I wrote a post about kindness in healthcare (Kindness is underrated) which referred to a recent book co-authored by a medical psychotherapist; Dr. Penelope Campling, who was Clinical Director of the Leicestershire Partnership Trust of NHS England (National Health Service). The glowing ‘everyone should have to read this book’ review I quoted from was written by no less than the President of the UK’s Royal College of General Practitioners.
That book was entitled “Intelligent Kindness: Reforming the Culture of Healthcare” and I’ve finally found and ordered a copy on-line; I should be reading this one soon, after a few others I’m also trying to find time to read! In the meantime, Dr. Campling has just penned an editorial in BJPsych Bulletin (published by the Royal College of Psychiatrists), on “Reforming the Culture of Healthcare: The Case for Intelligent Kindness”.
In this editorial, she outlines some of “the forces that create perverse dynamics that can pull in the opposite direction” from the ‘intelligent kindness’, which we should be trying to foster in healthcare environments:
– Emotional task
– Problematic team-working
– Problematic organisations
– Perverse dynamics
She then sets out 4 key factors which may have led to changes in how society views healthcare, and in how those working in the field may now perceive their roles: “There appear to be four closely intertwined processes at work. None of them is perverse in itself, but separately and together they can create perverse dynamics in the context of healthcare”:
1. Active promotion of a competitive market economy;
2. Process of industrialising healthcare;
3. Framework and currency of specification, regulation and performance management; and
4. Rise of consumerism and the promotion of patient ‘choice’.
The way I view these factors, from a Canadian perspective, are:
1. Viewing healthcare as commodity within a competitive market economy – the current situation in the US – runs counter to the United Kingdom (and I’d argue Canadian) view that our goal in the provision of universal healthcare is “an integrated service that prioritises the needs of vulnerable patients”. Unlike many (very outspoken) citizens of our largest neighbor, the US, we don’t view it is acceptable or normal that a family would be bankrupted by healthcare costs resulting from an illness or injury.
2. The industrialization of healthcare can be viewed negatively more in terms of the mechanisation of healthcare delivery than as a desire to give up all of the technical tools that modern medicine has at its disposal; from magnetic imaging, to genetic testing, to surgical robots. One of the most common complaints I see from physicians on social media (primarily LinkedIn and Twitter) is that using time-consuming and ‘clunky’ EHR/EMR systems makes them feel that their primary role is to interface with a computer, rather than to care for patients.
3. Performance management. I’m not arguing that we should abandon all metrics involved in how healthcare impacts each of us across the vast spectrum that encompasses pre-natal care, preventive medicine, palliative care – and everything in between. Information, or metrics, are important on issues so diverse they include population-level health indicators (from infant mortality through to life expectancy), public health data (such as disease prevention and tracking of epidemics), and hospital trend tracking (for example surgical infection rates and re-admissions).
Or that there’s no place for individual performance assessments in healthcare; for rewarding those who make a positive difference in patients’ lives, and perhaps providing incentives to improve (or leave) for people who make a negative impact on patients. But I feel that there’s been too much of an emphasis in recent years on performance measures, such as vague patient satisfaction surveys, that don’t necessarily relate to any real improvement in health outcomes.
4. The shift to viewing patients as consumers in many circles, which seems to have replaced one of the core tenets of bioethics (respect for patient autonomy) with a view that patient choice is mainly influenced by marketing. By this I mean the outlook that selecting a physician or hospital is akin to choosing whether to order pizza from restaurant A or restaurant B, that devalues the importance of the relationship between a patient and a physician, nurse, or other healthcare professional.
Her view seems to be that taken together, and over the long term, these 4 systemic factors may suck the kindness out of healthcare professionals. I wonder how many of them would agree.
(1) Campling, Penelope. Reforming the Culture of Healthcare: The Case for Intelligent Kindness. BJPsych Bulletin 39.1 2015; 1–5. PMC. Web. 18 Aug 2017