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Kindness is the foundation of positive human relationships. Kindness is also the foundation of quality anaesthesia, framing not just the goals of care but the paths we tread to reach them: kindness to our patient, kindness to one's team, and kindness to oneself. Kindness is the oxygen that sustains our practice.

"[Kindness is] helpfulness towards someone in need, not in return for anything, nor for the advantage of the helper himself, but for that of the person helped." – Aristotle, Book II of Rhetoric

Like many anaesthetists, I often fixate on outcomes. Yet for patients, the journey often matters as much as the destination. While modern medicine makes successful outcomes the lowest bar, the hospital experience shapes the patient's entire perception of care, sometimes turning a medical success into a perceived failure. When we centre our practice on kindness, we elevate both process and outcome, giving them equal weight.

Too often we equate quality anaesthesia with technical excellence: precise techniques, rapid turnover, stable vitals, adherence to best practices. We audit hard markers like pain scores and discharge times. Yet this reductionist approach misses the cornerstone of healthcare: kindness.

When we view our practice through the lens of kindness – not empathy, for it helps no one for the anaesthetist to experience the same pains and fears as their patient – we reorient our decisions around "how can I help this person?" with a clarity of purpose unburdened by personal gain. This perspective expands our care to embrace the whole person under our care.

Patient fears before anaesthesia and surgery become just as important to address as the technical aspects of care. Technique choices are no longer made for the convenience of the anaesthetist or hospital, but rather for the needs of the patient. Perioperative care rooted in kindness recognises the interconnection between patient experience and patient outcomes – the two factors that truly matter to those under our care.

This practice of kindness extends beyond the patient. It reshapes and reorients the way we engage with our team and ourselves.

Kindness to our team means fostering a culture of supportive communication: listening to concerns, acknowledging contributions, and responding to mistakes with constructive compassion. How often do you thank your assistant and surgical team at the end of a list?

Kindness becomes even more critical in moments of crisis. The stress you feel is likely shared by everyone in the room, and they look to you for both professional and emotional leadership. Maintaining calm, staying composed, and offering reassurance transforms a team’s performance under pressure. By contrast, a moment of sharp anger can unravel team cohesion, leaving lasting damage. In a crisis, anger is a poison that corrodes collective resilience.

Kindness to oneself may be the hardest form of kindness to practice. In a field where the bar is set so high, self-compassion is essential as we struggle to accept imperfect outcomes or personal errors. We must see mistakes not as failures but as opportunities for growth. The long hours, the high-intensity work, a sometimes-capricious health system, and the unpredictability of anaesthesia all contribute to burnout. It’s easy to get lost in our vocation, but we must recognise that life cannot be all work. Our families, our friendships, and our health must take priority. Kindness to ourselves is not indulgence; it is self-preservation.

In our demanding profession, perhaps the best advice is simple:

"Be a little kinder than you have to." – Emily Jenkins.

When we practice with kindness – to our patients, our team, and ourselves – we create an environment where care is more than just a technical exercise. We cultivate a virtuous cycle: supported team members provide better patient care; well-cared-for patients make our work more fulfilling.

And when we are kind to ourselves, we have the emotional resources to extend that kindness to others. In anaesthesia, as in life, kindness is not just a virtue – it's the vital sign that reflects the health of our practice. Kindness is an act of compassion that elevates routine care, benefiting everyone involved.

In anaesthesia, sitting at the point where the ideal meets reality, is compromise.

Compromise is the practical, real-world necessity that allows a health system to function in the face of competing demands. Every point of care in a hospital is a balance of compromises, frequently between safety and the many other flavours of medical quality.

For anaesthesiology the most common compromise is balancing safety with the quality of the patient experience: pain, distress, cost, delays, efficiency, levels of intervention, seniority of care… (Though let’s acknowledge, suffering injury because of a safety compromise is also a pretty poor patient experience.)

In a dynamic world of external stressors (<cough>pandemic<cough>) compromise becomes both more important and more fraught. How do we balance conflict between the needs and priorities of care? Compromises are then a pragmatic necessity, recognising the fractal complexity of patients and hospitals that the inherently reductive nature of best practice and theory struggles to accomodate.

A great example of this is found within the Zero Harm safety movement, aspiring to the worthy (though naive) goal of reducing healthcare staff & patient injury to zero. Zero Harm’s mistake is to build an entire ideology upon an unachievable goal, for as Thomas points out in 'The harms of promoting Zero Harm':

“...some harms are inevitable and impossible to eliminate.”
– Thomas (2020)

Zero Harm is itself a compromise, deprioritising other components of care in service to absolute safety. Only by recognising the natural compromises at every level of the health system can we make informed decisions about the risk-price we are willing to pay for compromise.

Many years ago as a junior resident, a senior colleague dropped some wisdom about compromise that sticks with me today. He made the observation in the setting of one of the commonest and discrete medical interventions: intravenous cannulation. Sometimes you have a cannula that is smaller or not flowing as well as you would prefer. Depending on the circumstance, this is often tolerable and we grudgingly accept it.

"But beware”, he said, “never allow more than one compromise.”

Although imperfect intravenous access may be a small compromise, it represents an increased-risk point of failure. Perhaps you now feel compelled to accept a ‘minor’ airway compromise (LMA over an ETT?), or a fasting compromise, or location, or the presence (or not) of a parent at induction? While each step may be justifiable, stacking compromises increases points of failure and risk in a non-linear way.

Stacked compromises increase risk geometrically.

Stacked compromises are fragile.

While there may be no true hard rules in anaesthesia, we need to appreciate that risk exists on a dynamic spectrum. The adolescent ideology of Zero Harm may have near Zero Place in anaesthesia, yet the primacy of risk management and harm minimisation always requires considering how our compromises interact and compound to alter the risk profile of the care we provide. Our goal in managing risk in complex systems should be to reduce risk where we can, and build resilience where we cannot.

You may still feel it necessary to stack your compromises, but by the Gods of Anaesthesia, if you do then you better make sure you know the price being paid – and who is ultimately paying it.

• Explore more in the metajournal knowledge collection: Reducing health-system harm: Safety I vs Safety II.

The 2020 coronavirus pandemic for all it's horror and challenge, has highlighted certain uncomfortable truths about the human condition. One of these has been the impact of our cognitive short-comings: our difficulty understanding the non-linear and non-binary, and our susceptibility to cognitive biases.

Many of these problems led to missteps at the beginning of the pandemic response, and now early in the fight continue to impede our decisions. By better understanding these cognitive traps we can at least be more alert to our blind spots and alter our actions in response.

As early data seeped out of China in January, quickly followed by cases appearing in global travel hubs, many national governments along with their populations refused to acknowledge the pandemic threat. Even as Northern Italy's health system first bent then broke, surpassing China's own COVID death count a mere 47 days after Italy's first confirmed case, world governments continued to water-down the threat.

Read on about exponential growth and biased thinking...

It’s not uncommon to hear anaesthesiologists drop verbal markers of universal truths into their clinical utterances: always, every, never. Often it's the most banal practices ("always attach the cannula tegaderm so") that generate our greatest passions.

However there are few, if any, universalisms in anaesthesia. Almost every rule has caveats and exceptions, reflecting the shades-of-grey reality of patient needs and human physiology.

When clinicians decree something is always or never so, they are often confusing truth with convention. Sometimes confusing an absolute with what is instead dogma. A minority reveal the rigidity of their thinking, impeding rather than enhancing the performance of their practice.

Rules are still useful. They are important guardrails, a mental model to keep us on the road of safety unless there is very good reason to cautiously edge onto the gravely shoulder, or even turn down a completely new path. But always with the understanding of the compromise we have intentionally made, reminding us of the cost that may need to be paid.

Universal anaesthesia rules become a problem when we dogmatically extol them without understanding the foundations of why – or use them as a blunt tool to browbeat our colleagues and assistants.

Rules are shortcuts to express the tension between the benefits and risks of different anaesthetic decisions. All difficult airways in specialty exams might require mandatory awake fiberoptic intubation, but in a real world of patient refusals and modern airway toys & techniques, it is a more nuanced decision. In fact, patient refusal might be the closest we get to an absolute rule – but even this is a negotiable area of greys.

As a mental model for normalising risk, rules are an efficient way to communicate our prioritisation of the risk-benefit tension. A tool for education and standard setting, without requiring the immediate overhead of qualifying and rationalising.

First learn the rules. Then master the rules. And only then can you break the rules.

The danger comes when we confuse the mental model – the guardrails – for the reality. Misidentifying a tool to guide perception and practice, as something we mistakenly believe reality can be bent to. When we make this error, reality has a nasty habit of reasserting itself with unsentimental brutality.

I made my mistakes so you don’t have to. Don’t repeat my mistakes. Make your own mistakes. Make better mistakes.