Healthcare education needs radical reform to emphasise careful and kind care
- Suzie Bailey, director of leadership and organisational development1,
- Dominique Allwood, director of population health2 3,
- Nicki Macklin, PhD candidate4,
- Victor Montori, professor of medicine5,
- Maureen Bisognano, president emerita6,
- Bob Klaber, director of strategy, research, and innovation2 3
- 1King’s Fund, London, UK
- 2Imperial College Healthcare NHS Trust, UK
- 3Imperial College London, UK
- 4Faculty of Medicine and Health Sciences, University of Auckland, New Zealand
- 5Mayo Clinic, Rochester, Minnesota, USA
- 6Institute for Healthcare Improvement, Massachusetts, USA
Healthcare professionals and the organisations in which they work are increasingly expected to respond to the expansion of disease burden and chronic multimorbidity, persistent health inequities, and problems with quality and care variation.1 To tackle these unprecedented demands and a health workforce under pressure, the response—focused heavily on access, productivity, and efficiency—has industrialised healthcare to the point that it is becoming dehumanised, transactional, generic, burdensome, and cruel. Healthcare is being depleted of care.2
Like the causes of this crisis of care, the solutions are complicated. However, an important way forward would be to reposition caring as the core purpose of healthcare systems, with clinical expertise and operational capacity focused on cultivating conditions that can foster care. Healthcare should be careful—that is, safe, based on the best evidence, and co-created with each patient to support their health goals and priorities.3 Care should also be kind and provided in easy to navigate and respectful services, causing minimal disruption to people’s lives and the lives of their caregivers.2
Clinicians seeking to offer careful and kind care must be able to mobilise both compassion and competence. This requires being curious about each person they meet and being able to see each as an individual, rather than as “blurry” cases, test results, or medical record entries.2 Clinicians need time to notice each patient’s biology and biography,4 which is key to understanding how social determinants of health and inequity may affect their illness and ability to cope and thrive.
Evidence shows that strong relationships between healthcare professionals and their patients and families are associated with enhanced patient experience, increased health literacy, and better health outcomes.567 As kindness is increasingly associated with healthcare quality,891011 it should be the starting point for how healthcare workers are trained, what they learn, and how services are led and experienced.12
Caring curriculums
However, achieving this is unrealistic without a major reorientation of healthcare professionals’ education and the health systems that provide the learning and caring environment. Formal medical curriculums have begun to focus on the value of being caring and “professionalism.” Yet the “hidden curriculum” of clinical practice effectively shapes professional identities,1314 conveying what is currently most valued in today’s practice: a technically correct response delivered transactionally to fix biological deficits.
Health educators (in medical and nursing schools, for example) can foster curiosity in their learners by developing their engagement and co-production skills, encouraging them to work with patients and communities to understand what matters to them. We know that understanding patients’ stories improves quality of care.15 Methods based on narrative medicine respond to this evidence and need to become more widespread.15 A pilot of a compulsory “human kindness” curriculum for first and second year medical students in California, for example, found that it significantly improved students’ empathy for patients, and protected students’ compassion from its typical decline during their clinical years.16
Intentional role modelling at the actual, simulated, or virtual “bedside” is an important educational method that allows learners to appreciate the role of relational and communicative skills alongside diagnostic and problem solving capacity. To develop their relational skills, learners must move out of the classroom to the bedside and use reflective practice with role models who can help them reconnect to what made them want to join the caring profession in the first place, finding their “mission and renewal in caring for and about their patients.”17 These critical relational aspects of care, such as the kindness, listening, communication, and understanding shown to patients in their most vulnerable moments, positively influence patients and families’ perceived experiences of healthcare.18
The methods used to assess learners’ capacities must also move beyond outdated approaches based on knowledge recall, which foster competitive behaviours and depersonalisation, and take a more holistic approach. This includes assessing learners’ emotional intelligence, curiosity, and handling of uncertainty; their analytical and critical thinking skills; and their ability to listen, engage with a patient’s problem, and communicate facts, findings, failures, and feelings.
A concerted effort to close the widening learning gap towards kind and careful care demands a radical reform of healthcare education and curriculums to foster kinder environments within which to learn, and in which people can become better prepared to care. This reform must accompany radical changes in healthcare itself: organisations must be led with kindness and compassion, caring for those who care for patients so that, together, they can care better for, about, and with patients.319 Without a fundamental change in healthcare, reformed healthcare education will merely result in healthcare staff who quickly discover that in industrialised healthcare their disposition to care fits only if deployed in standardised, transactional, and efficient interactions.
Such transformation will require a seismic shift in the value placed on relationships of care and on kindness—a shift that must be underpinned by structural changes at sociopolitical, physical, cultural, educational, and leadership levels. To face the unprecedented global demands on healthcare and the healthcare workforce, we must make a deliberate move away from industrial healthcare. The healthcare community—including leaders in educational institutions—need to create an educational and practice environment that cultivates and supports healthcare professionals toward careful and kind care.
Footnotes
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Competing interests: We have read and understood BMJ policy on declaration of interests and declare that VM is a member of the editorial advisory board for The BMJ.
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Provenance and peer review: Commissioned; externally peer reviewed.
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This article is part of a collection proposed by the Health Foundation, which also provided funding for the collection, including open access fees. The BMJ commissioned, peer reviewed, edited, and made the decision to publish these articles. Rachael Hinton and Paul Simpson were the lead editors for The BMJ.
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