Talking to health care professionals about the importance of loving your patients and colleagues — as I often do — might raise eyebrows.
How can we be expected to love our patients during a 15-minute clinic visit? How can love form among hospital teams coming together for a surgical procedure but then moving on to other work? Perhaps most importantly, how will this love make any difference in our patients' lives when they need their next medication dose or to be prepared for a procedure?
Yet the more we learn about how love and other emotions work, the more we recognize the immense power of love over the quality of care we deliver and over our efforts to improve that care. We also understand that this form of love is indeed practical and attainable in our hospitals and clinics.
Biomedical and social scientists alike are helping us understand how positive emotions help open ourselves to others, while negative emotions can break the bonds between people and even harm the performance of clinical teams.
Let’s explore a few of these emotions.
Love as Evidence-Based Medicine?
First, understand that the version of love that we're talking about has nothing to do with unconditional devotion, loyalty or a grandmother's affection for a child. It's a biological response. In her book Love 2.0, University of North Carolina psychology professor Barbara Fredrickson explains that this supreme emotion is experienced when two people have "micromoments of positive resonance" as they open themselves up to one another, feel warm toward each other and connect. A key component in this response is the release of oxytocin into the bloodstream. This hormone "appears both to calm fears that might steer you away from interacting with strangers and also to sharpen your skills for connection," she writes. "Rather than avoid new people out of fear and suspicion, oxytocin helps you pick up on cues that signal another person's goodwill and guides you to approach them with your own."
For many years, she explains, scientists focused on how oxytocin surges during sex, childbirth or lactation, when people are forging or strengthening new bonds with one another. Yet research took longer to recognize the subtle oxytocin spurts during everyday activities, such as playing with one's kids or putting an arm around a co-worker. People crave these moments of "love," regardless of whether they are connecting with a spouse, a colleague or a stranger.
That's where this concept resonates so powerfully for health care. We know that our moments with patients and peers are often fleeting, and loving them in the conventional sense seems unrealistic. Yet when you understand the power of those loving micromoments, you unlock a secret to positive patient experience. Patients, their families and loved ones are vulnerable and worried. Will the diagnosis be malignant or benign? Will the treatment work? Will I be able to work, to garden, to have sex? This is where true acts of love — a light touch, a gentle smile, a caring conversation — can calm and connect them. We can signal our goodwill and open the door to more honest discussions about their concerns and goals for care.
These lessons apply to how clinicians treat one another as well. There are few ordeals as emotionally draining as contributing to a medical error. As Joseph Bienvenu and I wrote in a recent JAMA op-ed, one all-too-common response of colleagues to such events has been to trigger shame — a feeling not just that I did something wrong, but that I'm a bad person. Shame makes us less likely to learn and grow from a mistake, or to tackle the underlying reasons for the error. A better, but still flawed response, is guilt: I did a bad thing. What am I going to do about it? While guilt can provide focus, it causes us to fixate on relieving our bad feelings and not much else.
The best response involves treating a mourning, distraught clinician with love: "when we seek to understand others, assume positive intentions, show respect and engage in shared accountability." Love allows us to be self-reflective and self-critical without self-loathing. Such a response would engage clinicians to reduce risks to future patients, even as we hold them and ourselves to high standards.
Chain Reactions of Generosity
From the biology of love, we move to the sociology of generosity and kindness. There is growing research by sociologists showing that generosity can be infectious — that experiencing or seeing generous acts can prompt people to "pay it forward" with similar acts. Almost two years ago, I witnessed a chain reaction at an inner-city Baltimore doughnut shop. After I helped a homeless couple buy their breakfast, one customer after another began buying meals for other homeless people standing in line.
In a New York Times op-ed a few months later, Cornell University sociologists explained how "a single act of kindness can in fact ripple through a social network, setting off chains of generosity that reach far beyond the original act."
The article helped explain the doughnut shop event and got me thinking about the potential implications for health care. It provides hope that, even in clinical areas where morale is low, individual acts of kindness or courage have the power to cascade through an organization. This may come in the form of a nurse who helps another nurse through a difficult patient case, a physician who says thank you to an environmental services worker for helping reduce risks of infections, or an employee who sees a lost and confused patient in the hospital corridors and walks him or her to where he or she needs to go. We believe that such acts become infectious, as recipients of such kindness become givers, and research suggests that it is possible.
The Toll of Rudeness
If love and generosity can connect people, rudeness and other disruptive behavior can break those bonds.
A fascinating study from Israel, published in August, helps support the theory that rudeness in clinical settings isn't just off-putting and bad for morale; it's potentially dangerous to patients too.
In a simulated neonatal intensive care unit, 24 clinical teams — each with a physician and two nurses — were asked to diagnose and treat an emergent condition. Minutes before starting the simulation, half of the teams were subjected to rudeness: A "welcome message" from an American surgeon criticized the quality of care in Israel and joked that he hoped he wouldn't get sick during his visit.
As Trevor Foulk, one of the study authors, wrote in The Conversation, the results "were staggering and frightening. The groups that were exposed to the rude comment did far worse in the simulation. A simple insult from a third party virtually destroyed the performance of the participants. Both their diagnostic skills and their performance suffered dramatically — meaning not only did they have a harder time figuring out what to do, but that even when they knew what to do, they had a harder time doing it." Though most clinicians treat each other with respect, disrespectful acts can demoralize the victim, decreasing their performance and increasing the risk for error.
Discussing their results, the researchers suggest that rudeness interferes with the cognitive functions that handle planning, management or analysis of goals. Exposure to rudeness may also undermine the collaborative processes that might otherwise help teams to mitigate the worse performance of one or more members.
What should we do with these findings about love, generosity and civility? Perhaps it's simply a deeper recognition that we can carry throughout all interactions: Emotions matter, perhaps more than we understand.
We can recognize that the secret sauce of improvement and patient-centered care — and life in general — is not some technical solution or a checklist. These are helpful, yet they are not the mojo of life. We need to create these micromoments of positive resonance between clinicians and patients, and clinicians with each other. To quote the father of quality improvement, Avedis Donabedian, "Ultimately, the secret to quality is love." And it is contagious.