What makes one person kinder than another? Is the difference due to temperament, with some people endowed with greater empathy than others? Perhaps. Is the difference due to an individual’s system of belief, with some people making kindness part of their religious, spiritual or moral practice? Undoubtedly. Today, however, I focus on a crucial aspect of kindness that is often ignored: engaging in acts of kindness takes skill.

Let’s look at some examples.

Dr. Atul Gawande, a gifted and prolific writer and surgeon at Brigham and Women’s Hospital in Boston, has written in his 2014 best-selling book “Being Mortal” about his own short-comings in kindness when caring for terminally ill patients. When he’s being interviewed, Dr. Gawande often speaks about how he came to his realization that his bedside manner was not increasing the well-being of his patients. He became concerned and began to re-evaluate the way he spoke with terminally ill patients about what they could expect in their remaining days and what their treatment options were. At one point he decided to go back to speak with patients he had previously spoken to and ask them how they had perceived him when he broke the news to them of their impending deaths. One patient said that Dr. Gawande’s words felt like a sledgehammer to him and yet they were delivered in a way that made the patient feel Dr. Gawande didn’t care.

Such clarity in the feedback served as a wakeup call to Dr. Gawande and led him to explore his own behaviors and that of colleagues. He writes that, for example, 97% of medical students in the United States never take a Geriatric Medicine clerkship. He realized that our collective short-comings in dealing with issues of death and dying when caring for our patients often grow out of our lack of skill and training in these topics. He writes how the best way to improve one’s bedside manner regarding these crucial end-of-life topics is to have someone demonstrate to you how it is done, and then mentors you in this process. Too often, however, such demonstrations and mentorship is not available. So, we continue to stumble in the dark, aware that we could be doing better but not knowing how to do so. Also, too often we do not feel confident enough to ask other clinicians for their help or advice. Our medical culture prizes decisiveness and independent decision-making. So, we can quickly build up our emotional armor to distance ourselves from the discomfiting but vague concerns regarding our shortcomings in speaking to and being with our patients. We shrug and move on. There are always more patients to see, more procedures to learn, and more paperwork to complete.

Just so you don’t think that psychiatrists are immune from such challenges, let me share an example from psychiatry. As you may know, I have trained several thousand psychiatrists to help them pass their oral boards. As I never tire of saying, the oral boards are not simply an exam of knowledge but also of performance. And good performance takes skill. You may also have heard me say that the quickest way to fail this exam – which still continues to this day on a reduced basis– is to breach rapport with the patient. Ways of breaching rapport include making disrespectful comments, displaying a pattern of not listening to the patient, and not displaying an empathic response when the patient shares information regarding a traumatic experience with the interviewing psychiatrist.

One of the most common questions I have fielded over the many years of the Beat The Boards! course by exam candidates is how they should display empathy when the patient shares painful experiences with them. (The foundation of how to behave empathically, by the way, is to stop what you are doing and pay attention. How you then respond, verbally or non-verbally, is of secondary importance. The patient needs first to know that they have been heard and that the import of their revelation was not lost on you.)

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In addition to fielding questions, I also regularly saw instances of quite unempathic behaviors from exam candidates. There were a handful of times when, for example, a patient shared in the interview that their child had died at some earlier time. In response, some candidates would look down to jot a note and proceed to ask an unrelated question. When during the feedback session I chided these examinees about their handling of this interview scenario and asked them to explain their reaction – or lack of reaction – I usually heard something to the effect of, “I was worried that I would open a can of worms,” or “I was afraid that it would take too long to discuss this topic,” or “I was worried this might make the patient too emotional.”

To me all of these examinees’ explanations for their handling of the interview situation had the common thread of expressing discomfort with knowing how to deal with the patients’ disclosures. I wasn’t left thinking that the candidates were self-centered or unempathic people. Rather I was left thinking that their unempathic reaction was due to a shortcoming of skill – as well as the stress of a mock-exam scenario. As a result, at the course the entire group of participants and I would spend quite a bit of time exploring how to respond when confronted by sensitive patient disclosures and then practicing empathic responses. It worked.

These two examples are drawn from our work as professionals. I’m confident we can all come up with a list of examples from our personal lives. Sure, many factors come into play when in hindsight we realize our behaviors were less than kind. But rather than beating yourself up, consider first, “what skills could I learn, what behaviors could I practice, to help me become a kinder person.

Please share your thoughts by emailing me. Next week I cover another underappreciated aspect of acting kindly, what I call “The Space of Kindness.”

Until next time,

Dr. Jack


It’s Raining Cats and Dogs

This week’s LanguageBrief discusses the origins of the idiom, “It’s raining cats and dogs.” The actual origins of this phrase are hard to come by. Here are three possible explanations. Since there is no definitive information on which is correct, you can choose your favorite explanation.

One story states that back in the Middle Ages in England, most cottages had thatched roofs that afforded a warm place to sleep to dogs, cats, mice, and other small animals found in this rural environment. If the rain was heavy, the animals living on or within the thatch would slip and fall to the ground.

A second origin story is that in medieval times witches were thought to ride large black cats through the sky. And, additionally, the Norse storm god Odin was the god of dogs and wolves. Thus, if the rain was particularly heavy, it was said that it rained cats and dogs. Presumably, the wolves were not affected and remained airborne.

Our last possibility is that in centuries back, the streets were so filled with filth of all manner that during heavy rains dead animals, including cats and dogs, were swept into swollen rivers and streams. I always read this idiom as meaning that cats and dogs fell from the sky during heavy rain. But this last story makes me realize that our idiom does not state this explicitly. Dead floating cats and dogs therefore remain a possibility.

So choose your favorite. Or let me know of other, including your own made-up, possible explanations.