commentaries Emotional intelligence: convinced or lulled? Nancy McNaughton & Mohammad S Zubairi In this issue, Cherry et al.,1 the authors of ‘Emotional intelligence: a critical review’, provide a welcome examination of emotional intelligence (EI) as a theoretical platform focusing on clinical educators’ ‘critical questions’. Recognising that emotion is integral to the reality of medicine as an ‘emotionally demanding practice’1 is an excellent point from which to extend our knowledge about its place in medical education. Emotional intelligence is an umbrella under which we in medical education have come to group many of our anxieties about the immeasurable non-cognitive qualities integral to medical training. Emotional intelligence is considered an unassailable good reflecting the importance of care and compassion in the face of suffering. However, we would like to suggest, as do Cherry et al.,1 that we tread carefully with respect to the application of EI as the basis for medical school admission, communication skills education and professionalism. Employing the construct of EI, in which emotion is viewed as a set of teachable individual skills and behaviours, risks our devaluing of emotion in practice. Such emphasis discounts the effects of distributed social and Toronto, Ontario, Canada
Correspondence : Nancy McNaughton, Standardised Patient Programme, Faculty of Medicine, University of Toronto, 88 College Street, Toronto, Ontario M5G 1L7, Canada. Tel: 00 1 416 946 3310; E-mail: [email protected] doi: 10.1111/medu.12455
456
cultural rules about emotion on professional socialisation and wellbeing. In this commentary, we suggest that by additionally acknowledging emotion as a socially and culturally mediated phenomenon, we may better serve our students and practising colleagues.
Recognising that emotion is integral to the reality of medicine as an ‘emotionally demanding practice’ is an excellent point from which to extend our knowledge about its place in medical education
The constitution of emotion as a kind of intelligence rests on the development of the intelligence quotient (IQ) at the turn of the 20th century by psychologists such as Goddard and Wechsler, who were instrumental in transforming psychology into an empirical science at the forefront of a widespread social reform movement. Like emotion, intelligence has been surrounded by ideas that reflect the source and purpose of the group that is deploying it as a classification as much as any inherent truth. Shifts in ideas about IQ tests have occurred over time. Intelligence, first seen as a set of inherited traits responsible for global emotional, mental and moral functioning, later came to be thought of as an ability or adaptive capacity.2 Like IQ, EI is a historically contingent construct vulnerable to changes in ideas about its legitimacy and relevance in theory and practice. Understanding the purposes for which EI is deployed is directly relevant to education generally and medical education
specifically. As Cherry et al.1 point out: ‘The popularisation of EI as “mattering more than IQ” has promoted it as a crucial attribute for successful psychological and social functioning.’ Like IQ, EI is a historically contingent construct vulnerable to changes in ideas about its legitimacy and relevance in theory and practice
Within a theory of EI, concepts of ‘intelligence’ and ‘emotion’ converge along a trajectory related to ideas about ability, skills and performance. Psychological ascertainment of an individual’s EI justifies educational reform activities through which intelligence and moral character can be observed, trained and assessed. However, to view emotion solely through an EI-framed lens renders invisible the implications that such a move produces. As Cherry et al.1 suggest, making EI a marker of suitability for medical school and a measurable factor in one’s success upon gaining entry ‘will inescapably focus people’s attention in a way that could, ultimately, trivialise the very quality it was intended to strengthen’. Psychological ascertainment of an individual’s EI justifies educational reform activities through which intelligence and moral character can be observed and assessed
Emotional intelligence represents a behaviourist approach of
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 456–465
commentaries repeated exposure, practice and feedback, in which clinicians are trained to attach the right emotions to the right skills for professional performances. Ideas about professionalism and social accountability underlie the need for communication skills training: if clinicians are unable to control their own emotions, how can they be trusted with their patients’ concerns? Where emotion is taught as part of communication skills within formal curricula, this occurs largely with standardised patients (SPs) to develop surface behavioural techniques for improving eye contact, using open and closed questions, building rapport and expressing empathy. As Cherry et al.1 and others3–5 have noted, such coaching has its dark side. Hanna and Fins3 write: ‘The medical student may, through practice in simulation encounters, be able to master all the skills and tricks of surface communication and be able to use them very effectively in an OSCE [objective structured clinical examination] . . . as a set of acting techniques.’ Additionally, thinking about emotion in this way allows a medical student’s empathy or altruistic sensibility to be measured on a multiple-choice item questionnaire as right or wrong, or plotted onto a checklist during an observed performance with an SP, as if this student’s ‘values, attitudes and behaviours’ represent a single, de-contextualised observable assemblage’.6 The focus shifts to outcomes and emerging professionals are treated as reliable products. Emotional intelligence represents a behaviourist approach of repeated exposure, practice and feedback
Debates about whether EI is a skill, trait, ability, physiological process, competency or theory are ongoing and are accompanied by associated
measurement dilemmas. Constructing emotion as simply another form of cognition does not go far enough towards recognising our need to develop models that expand understanding about how to meaningfully engage emotion in medical education. Does the focus on individual skills and abilities push aside the more subtle relational characteristics of emotion in action? Ideas about emotions in medical training have material effects that range from medical student burnout to patient safety. We suggest that emotions are a social as well as a physiological and psychological phenomenon. For example, not everyone has the same permission to be emotional in particular contexts. This observation speaks not only of the traits and abilities of the individual, but of the social, cultural and professional contexts in which training and practice take place. Ideas about emotions in medical training have material effects that range from medical student burnout to patient safety
There is agreement among scholars working in the area of emotion and medical education that it is ‘extremely complex, still poorly understood and [that] research in this field is still developing’.7 In the interests of expanding the conversation beyond EI, we propose that a rich sociological history of emotion has much to contribute. Through diverse conceptual models, all of which share a common focus on emotion as an integral part of social relations, emotions are seen to be shaped by the social world. Undoubtedly, EI nods to ‘social intelligence’ on the basis that any ‘intelligence’ is demonstrated in social relationships. However, social intelligence is still a psychological construct that focuses inwards on an individual’s skills and abilities,
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 456–465
rather than outwards on the social conditions that make certain emotions acceptable and others not. Emotions are a social as well as a physiological and psychological phenomenon
As an example, Arlie Hochschild’s theory of ‘emotions as labour’8 has ongoing relevance for medical educators.9,10 Hochschild defines emotional labour as ‘requiring one to induce or suppress feeling in order to sustain the outward countenance that produces the proper state of mind in others’.8 In health professional work, there are implicit rules about feelings that require certain behaviours to be performed or repressed for the good of the patient, the professional or the profession itself. These focus on the social environments in which such rules are learned, not solely on the individual’s capacity to successfully acquire and correctly express them. Cherry et al.1 reference this idea by recognising ‘the importance of EI [. . .] in contexts that involve higher levels of “emotional labour”’, but within medical education emotion as a form of labour has not been given full attention; thus it represents a welcome direction for future inquiry. In health professional work, there are implicit rules about feelings that require certain behaviours to be performed or repressed
Other fruitful socio-cultural perspectives have roots in work-based, practice-oriented theories, all of which configure knowing as participation in dynamic social contexts. These cultural learning theories reinforce the centrality of knowledge acquisition as emotional as well as cognitive.
457
commentaries Emotion is a complex topic that crosses disciplinary boundaries and is central to the work carried out by health care professionals daily. The authors of ‘Emotional intelligence: a critical review’1 have contributed valuable insights into the benefits and continuing challenges represented by EI within medical education. We have an obligation as educators to continue such critical examinations and to broaden our theoretical and disciplinary horizons through conversation with one another in the spirit of discovery.
2
3
4
5
REFERENCES 1 Cherry MG, Fletcher I, O’Sullivan H, Dornan T. Emotional
6
intelligence in medical education: a critical review. Med Educ 2014;48: 468–78. Gould SJ. The Mismeasure of Man. New York, NY; London: W W Norton 1996;57. Hanna M, Fins J. Power and communication: why simulation training ought to be complemented by experiential and humanist learning. Acad Med 2006;81 (3): 265–70. Hodges B. The Objective Structured Clinical Examination: A Socio-History. Cologne: LAP Lambert Academic Publishing 2007. Bligh J, Bleakley A. Distributing menus to hungry learners: can learning by simulation become simulation of learning. Med Teach 2006;28 (7):606–13. McNaughton N. The Role of Emotion in the Work of Standardized Patients:
7
8
9
10
A Critical Theoretical Analysis. Cologne: LAP Lambert Academic Publishing 2012;75. Lewis N, Rees C, Hudson N, Bleakley A. Emotional intelligence in medical education: measuring the unmeasurable? Adv Health Sci Educ 2005;10:339–55. Hochschild AR. The Managed Heart: Commercialization of Human Feeling, 11th edn. Berkeley, CA: University of California Press 2003. Held S, McKimm J. Emotional intelligence, emotional labour and affective leadership. In: Preedy M, Bennet N, Wise C, eds. Educational Leadership: Context, Strategy and Collaboration. Milton Keynes: Open University 2012;52–65. Larson EB, Yao X. Clinical empathy as emotional labour in the patient–physician relationship. JAMA 2005;293 (9):1100–6.
The appeal of emotional intelligence Jessica A Ogle & John A Bushnell Nearly a decade ago, Lewis et al. raised the spectre of emotional intelligence (EI) as a ‘uroborus’: a construct so fraught with conceptual and measurement problems as to parallel the mythical animal ‘that eats itself, beginning with its tail, and so disappears by its own devices’.1 In this issue of Medical Education, Cherry et al.2 demonstrate how little has changed in the intervening years, despite the increasing attention
Wollongong, New South Wales, Australia
Correspondence : John A Bushnell, Graduate School of Medicine, University of Wollongong, Northfields Avenue, Wollongong, New South Wales 2522, Australia. Tel: 00 61 2 4221 5127; E-mail: [email protected] doi: 10.1111/medu.12433
458
paid to the skills and talents above and beyond the traditional cognitive and intellectual abilities required for the successful pursuit and practice of a medical career. Emotional intelligence and related concepts, including professionalism, interpersonal skills, compassionate and empathic patient care, and communication skills, have all been the focus of active research. For the dean of a medical school who is considering the determinants of the clinical safety of its graduates (and the reputation of the school), an absence or deficiency in these attributes is evident in an evaluation of public dissatisfaction and complaints pertaining to medical practice.3–8 As emotional topics are common in medical consultations and doctors will ultimately be challenged
for ways to respond to and skilfully manage emotions in medical practice, this evidence is perhaps unsurprising.
Emotional intelligence was presented as a ‘uroborus’: a construct so fraught with conceptual problems as to parallel the mythical animal
The idea that medical schools need to help students develop interpersonal as well as academic skills has become an accepted part of most medical curricula. Cherry et al.2 present a comprehensive review of the relevance of EI in the selection, training and performance management of medical students. Although a lack of clarity about the essence of
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 456–465
Correspondence : Nancy McNaughton, Standardised Patient Programme, Faculty of Medicine, University of Toronto, 88 College Street, Toronto, Ontario M5G 1L7, Canada. Tel: 00 1 416 946 3310; E-mail: [email protected] doi: 10.1111/medu.12455
456
cultural rules about emotion on professional socialisation and wellbeing. In this commentary, we suggest that by additionally acknowledging emotion as a socially and culturally mediated phenomenon, we may better serve our students and practising colleagues.
Recognising that emotion is integral to the reality of medicine as an ‘emotionally demanding practice’ is an excellent point from which to extend our knowledge about its place in medical education
The constitution of emotion as a kind of intelligence rests on the development of the intelligence quotient (IQ) at the turn of the 20th century by psychologists such as Goddard and Wechsler, who were instrumental in transforming psychology into an empirical science at the forefront of a widespread social reform movement. Like emotion, intelligence has been surrounded by ideas that reflect the source and purpose of the group that is deploying it as a classification as much as any inherent truth. Shifts in ideas about IQ tests have occurred over time. Intelligence, first seen as a set of inherited traits responsible for global emotional, mental and moral functioning, later came to be thought of as an ability or adaptive capacity.2 Like IQ, EI is a historically contingent construct vulnerable to changes in ideas about its legitimacy and relevance in theory and practice. Understanding the purposes for which EI is deployed is directly relevant to education generally and medical education
specifically. As Cherry et al.1 point out: ‘The popularisation of EI as “mattering more than IQ” has promoted it as a crucial attribute for successful psychological and social functioning.’ Like IQ, EI is a historically contingent construct vulnerable to changes in ideas about its legitimacy and relevance in theory and practice
Within a theory of EI, concepts of ‘intelligence’ and ‘emotion’ converge along a trajectory related to ideas about ability, skills and performance. Psychological ascertainment of an individual’s EI justifies educational reform activities through which intelligence and moral character can be observed, trained and assessed. However, to view emotion solely through an EI-framed lens renders invisible the implications that such a move produces. As Cherry et al.1 suggest, making EI a marker of suitability for medical school and a measurable factor in one’s success upon gaining entry ‘will inescapably focus people’s attention in a way that could, ultimately, trivialise the very quality it was intended to strengthen’. Psychological ascertainment of an individual’s EI justifies educational reform activities through which intelligence and moral character can be observed and assessed
Emotional intelligence represents a behaviourist approach of
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 456–465
commentaries repeated exposure, practice and feedback, in which clinicians are trained to attach the right emotions to the right skills for professional performances. Ideas about professionalism and social accountability underlie the need for communication skills training: if clinicians are unable to control their own emotions, how can they be trusted with their patients’ concerns? Where emotion is taught as part of communication skills within formal curricula, this occurs largely with standardised patients (SPs) to develop surface behavioural techniques for improving eye contact, using open and closed questions, building rapport and expressing empathy. As Cherry et al.1 and others3–5 have noted, such coaching has its dark side. Hanna and Fins3 write: ‘The medical student may, through practice in simulation encounters, be able to master all the skills and tricks of surface communication and be able to use them very effectively in an OSCE [objective structured clinical examination] . . . as a set of acting techniques.’ Additionally, thinking about emotion in this way allows a medical student’s empathy or altruistic sensibility to be measured on a multiple-choice item questionnaire as right or wrong, or plotted onto a checklist during an observed performance with an SP, as if this student’s ‘values, attitudes and behaviours’ represent a single, de-contextualised observable assemblage’.6 The focus shifts to outcomes and emerging professionals are treated as reliable products. Emotional intelligence represents a behaviourist approach of repeated exposure, practice and feedback
Debates about whether EI is a skill, trait, ability, physiological process, competency or theory are ongoing and are accompanied by associated
measurement dilemmas. Constructing emotion as simply another form of cognition does not go far enough towards recognising our need to develop models that expand understanding about how to meaningfully engage emotion in medical education. Does the focus on individual skills and abilities push aside the more subtle relational characteristics of emotion in action? Ideas about emotions in medical training have material effects that range from medical student burnout to patient safety. We suggest that emotions are a social as well as a physiological and psychological phenomenon. For example, not everyone has the same permission to be emotional in particular contexts. This observation speaks not only of the traits and abilities of the individual, but of the social, cultural and professional contexts in which training and practice take place. Ideas about emotions in medical training have material effects that range from medical student burnout to patient safety
There is agreement among scholars working in the area of emotion and medical education that it is ‘extremely complex, still poorly understood and [that] research in this field is still developing’.7 In the interests of expanding the conversation beyond EI, we propose that a rich sociological history of emotion has much to contribute. Through diverse conceptual models, all of which share a common focus on emotion as an integral part of social relations, emotions are seen to be shaped by the social world. Undoubtedly, EI nods to ‘social intelligence’ on the basis that any ‘intelligence’ is demonstrated in social relationships. However, social intelligence is still a psychological construct that focuses inwards on an individual’s skills and abilities,
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 456–465
rather than outwards on the social conditions that make certain emotions acceptable and others not. Emotions are a social as well as a physiological and psychological phenomenon
As an example, Arlie Hochschild’s theory of ‘emotions as labour’8 has ongoing relevance for medical educators.9,10 Hochschild defines emotional labour as ‘requiring one to induce or suppress feeling in order to sustain the outward countenance that produces the proper state of mind in others’.8 In health professional work, there are implicit rules about feelings that require certain behaviours to be performed or repressed for the good of the patient, the professional or the profession itself. These focus on the social environments in which such rules are learned, not solely on the individual’s capacity to successfully acquire and correctly express them. Cherry et al.1 reference this idea by recognising ‘the importance of EI [. . .] in contexts that involve higher levels of “emotional labour”’, but within medical education emotion as a form of labour has not been given full attention; thus it represents a welcome direction for future inquiry. In health professional work, there are implicit rules about feelings that require certain behaviours to be performed or repressed
Other fruitful socio-cultural perspectives have roots in work-based, practice-oriented theories, all of which configure knowing as participation in dynamic social contexts. These cultural learning theories reinforce the centrality of knowledge acquisition as emotional as well as cognitive.
457
commentaries Emotion is a complex topic that crosses disciplinary boundaries and is central to the work carried out by health care professionals daily. The authors of ‘Emotional intelligence: a critical review’1 have contributed valuable insights into the benefits and continuing challenges represented by EI within medical education. We have an obligation as educators to continue such critical examinations and to broaden our theoretical and disciplinary horizons through conversation with one another in the spirit of discovery.
2
3
4
5
REFERENCES 1 Cherry MG, Fletcher I, O’Sullivan H, Dornan T. Emotional
6
intelligence in medical education: a critical review. Med Educ 2014;48: 468–78. Gould SJ. The Mismeasure of Man. New York, NY; London: W W Norton 1996;57. Hanna M, Fins J. Power and communication: why simulation training ought to be complemented by experiential and humanist learning. Acad Med 2006;81 (3): 265–70. Hodges B. The Objective Structured Clinical Examination: A Socio-History. Cologne: LAP Lambert Academic Publishing 2007. Bligh J, Bleakley A. Distributing menus to hungry learners: can learning by simulation become simulation of learning. Med Teach 2006;28 (7):606–13. McNaughton N. The Role of Emotion in the Work of Standardized Patients:
7
8
9
10
A Critical Theoretical Analysis. Cologne: LAP Lambert Academic Publishing 2012;75. Lewis N, Rees C, Hudson N, Bleakley A. Emotional intelligence in medical education: measuring the unmeasurable? Adv Health Sci Educ 2005;10:339–55. Hochschild AR. The Managed Heart: Commercialization of Human Feeling, 11th edn. Berkeley, CA: University of California Press 2003. Held S, McKimm J. Emotional intelligence, emotional labour and affective leadership. In: Preedy M, Bennet N, Wise C, eds. Educational Leadership: Context, Strategy and Collaboration. Milton Keynes: Open University 2012;52–65. Larson EB, Yao X. Clinical empathy as emotional labour in the patient–physician relationship. JAMA 2005;293 (9):1100–6.
The appeal of emotional intelligence Jessica A Ogle & John A Bushnell Nearly a decade ago, Lewis et al. raised the spectre of emotional intelligence (EI) as a ‘uroborus’: a construct so fraught with conceptual and measurement problems as to parallel the mythical animal ‘that eats itself, beginning with its tail, and so disappears by its own devices’.1 In this issue of Medical Education, Cherry et al.2 demonstrate how little has changed in the intervening years, despite the increasing attention
Wollongong, New South Wales, Australia
Correspondence : John A Bushnell, Graduate School of Medicine, University of Wollongong, Northfields Avenue, Wollongong, New South Wales 2522, Australia. Tel: 00 61 2 4221 5127; E-mail: [email protected] doi: 10.1111/medu.12433
458
paid to the skills and talents above and beyond the traditional cognitive and intellectual abilities required for the successful pursuit and practice of a medical career. Emotional intelligence and related concepts, including professionalism, interpersonal skills, compassionate and empathic patient care, and communication skills, have all been the focus of active research. For the dean of a medical school who is considering the determinants of the clinical safety of its graduates (and the reputation of the school), an absence or deficiency in these attributes is evident in an evaluation of public dissatisfaction and complaints pertaining to medical practice.3–8 As emotional topics are common in medical consultations and doctors will ultimately be challenged
for ways to respond to and skilfully manage emotions in medical practice, this evidence is perhaps unsurprising.
Emotional intelligence was presented as a ‘uroborus’: a construct so fraught with conceptual problems as to parallel the mythical animal
The idea that medical schools need to help students develop interpersonal as well as academic skills has become an accepted part of most medical curricula. Cherry et al.2 present a comprehensive review of the relevance of EI in the selection, training and performance management of medical students. Although a lack of clarity about the essence of
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 456–465
