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Emotions, Narratives, and Ethical Mindfulness Marilys Guillemin, MEd, PhD, and Lynn Gillam, MA, PhD
Abstract Clinical care is laden with emotions, from the perspectives of both clinicians and patients. It is important that emotions are addressed in health professions curricula to ensure that clinicians are humane healers as well as technical experts. Emotions have a valuable and generative role in health professional ethics education. The authors have previously described a narrative ethics pedagogy, the aim of which is to develop ethical mindfulness. Ethical mindfulness is a state of being that acknowledges everyday ethics and ethically important moments as
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linical care is emotionally laden, both for patients and health care professionals. Doctors, nurses, and allied health professionals can and often do feel a range of emotions towards patients and colleagues. These include compassion for patients’ suffering and admiration for their courage, anger at patients who do not look after their own health, and resentment at colleagues perceived to be making poor decisions. Emotional responses in clinical situations can be problematic for students and health practitioners. There is some evidence to suggest that students and junior practitioners feel embarrassed or discomforted by patients’ emotions,1 and sense that if they enter into more than minimal emotional engagement M. Guillemin is professor, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia. L. Gillam is professor, Centre for Health Equity, School of Population and Global Health, University of Melbourne, and academic director, Children’s Bioethics Centre, Royal Children’s Hospital, Melbourne, Victoria, Australia. Correspondence should be addressed to Marilys Guillemin, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Melbourne, Victoria 3010, Australia; telephone: (+61) 3-8344-0827; e-mail: m.guillemin@ unimelb.edu.au. Acad Med. 2015;90:726–731. First published online April 7, 2015 doi: 10.1097/ACM.0000000000000709
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significant in clinical care, with the aim of enabling ethical clinical practice. Using a sample narrative, the authors extend this concept to examine five features of ethical mindfulness as they relate to emotions: (1) being sensitized to emotions in everyday practice, (2) acknowledging and understanding the ways in which emotions are significant in practice, (3) being able to articulate the emotions at play during ethically important moments, (4) being reflexive and acknowledging both the generative aspects and the limitations of emotions, and (5) being courageous.
The process of writing and engaging with narratives can lead to ethical mindfulness, including the capacity to understand and work with emotions. Strategies for productively incorporating emotions in narrative ethics teaching are described. This can be a challenging domain within medical education for both educators and health care students and thus needs to be addressed sensitively and responsibly. The potential benefit of educating health professionals in a way which addresses emotionality in an ethical framework makes the challenges worthwhile.
with patients and families, they will be judged negatively by their seniors. Dealing with this is part of professional identity formation, as junior practitioners must navigate how to handle emotional responses as they negotiate the kind of practitioner they want to become. Whilst emotional engagement with patients and families is recognized by medical educators as essential for good clinical practice2 and as more personally sustainable for doctors than detachment,3,4 this is not necessarily acknowledged or acted on in clinical practice.3
has gained increased prominence over recent decades.9–13 Our experience using this approach in teaching ethics is that students generally become emotionally engaged with the stories, often showing strong emotional responses during their discussion. This triggered our development of the concept of ethical mindfulness to include emotions.
Thus, it is important for health professions education to emphasize understanding and appropriate management of emotions. In this Perspective, we concur with medical educators calling for deeper examination of the role of emotions in health professions education,5,6 including the “emotional process” of becoming a physician.7 We suggest that ethics education is an appropriate place on which to focus, given that ethics teaching already deals with issues of professionalism and professional identity formation, self-care, and practitioner– patient engagement. To demonstrate how this may be achieved, we draw on our previously published work on narrative ethics which uses personal stories to develop ethical mindfulness.8 Narrative ethics is a broad field which
We begin by reviewing current debates on emotions and ethics, focusing on health professions practice and education. We then develop the concept of ethical mindfulness highlighting the relevance of emotions, using a narrative exemplar. We conclude with a discussion of the significance of this approach for health professional ethics education. The Uneasy Place of Emotions in Health Professional Practice and Education
Education in the health professions now routinely incorporates empathy; increasingly, medical curricula aim to promote related attitudes or emotions, in particular compassion and caring.3,14–17 However, learners often receive mixed messages. Emotions are commonly understood to have affective and cognitive components,18 both of which are important for understanding and regulating emotions. Despite this, there is a tendency amongst some medical education researchers to focus on the
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cognitive aspects, explicitly excluding practitioners’ emotional engagement with patients.19–21 This is problematic because the important task of cognitive assessment of affective responses is overlooked when the affective dimensions of health professionals’ responses to patients are not given due attention. Despite evidence that lack of engagement leads to burnout, there are still strong calls for maintaining detachment so as not to compromise clinical judgment or become emotionally fatigued.22–25 As Shapiro5 points out, messages about emotions delivered in the formal curriculum are often contradicted by the informal and hidden curricula, where detachment is exemplified and valorized. Although emotions are at least acknowledged in health professions education, it is our experience in teaching students that the emotions that are more uncomfortable or less socially acceptable, such as anger towards patients or colleagues, receive much less formal attention than, for example, maintaining detachment, though they are equally important. There is a growing literature that highlights the important and productive role of emotions in clinical care and health professions education.26,27 The capacity to engage emotionally has been shown to promote patients’ trust, willingness to communicate, and compliance, whereas detachment can lead to decreased trust and compliance in patients.4,10 Recognition of the inadequacies of the detached clinical version of empathy has prompted revised approaches to empathy in health professions education, such as Halpern’s28 “engaged curiosity,” which reincorporate the affective aspect. The skills required for this type of empathy—namely, selfreflection and the ability to constructively process emotions—are thought to be protective against stress and burnout.28 This suggests that it is both possible and necessary to educate health professionals more thoughtfully about the role of emotions in clinical practice. Emotions and Ethics
In the cognitivist tradition of ethical theory, on which contemporary health care ethics is largely based, emotions have mostly been seen as a disturbance or a threat to ethical practice. Ethical
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practice, commonly understood as ethical decision making, requires rational thought.29 In this standard picture, emotion interferes with reasoning, and hence is a hindrance to ethical decision making30; the process of ethical decision making requires distance from one’s emotions, in order to think clearly and objectively.30 Principlism is the most common foundation for ethics teaching in the health professions.31 Health care students are taught the classic midlevel principles,32 together with the analytic skills to use these principles.33 We suggest that this approach to teaching ethics does not pay sufficient attention to emotions. First, recent work in a number of fields has shown that emotions are not such a threat to reasoning. Klein34 showed how emotions are crucial for intuitive decision making in professional practice in health care and other high-risk occupations. Gigerenzer35 argued that gut feelings could be superior to the rational weighing of gains and possible harms. Although high-intensity emotions may prevent reasonable decisions, emotions of lower intensity are often used as a valuable advisor in decision making.36,37 Second, in ethical theory, emotions have a legitimate and important role, even in the cognitivist/rationalist tradition. In 1985, for example, Herman38 argued that emotions are important for moral sensitivity, which is the capacity to recognize that a situation is morally salient and requires ethical deliberation. Ethically appropriate action is not possible without moral sensitivity, according to Herman.38 More recently, Haidt30 has argued that teaching ethics without reference to emotions fails to prepare students for ethical thinking in the real world, because the real world is emotionally “hot” compared with the classroom. Haidt30 proposes that ethical thinking begins with a moral intuition, which is cognitive, but includes an affective component— namely, a feeling of approval or disapproval. Reasoning follows only if it is elicited by some feature of the situation. Reasoning is most often undertaken with others, such as friends or colleagues, rather than by oneself, and is influenced significantly by their intuitions and emotions. Reasoning can also be influenced by one’s feelings of discomfort
or fear, especially if one’s worldview and values appear to be challenged.30 These insights are significant for health professional ethics education and can be taken into account without adopting the emotivist position, first articulated by Hume,39 that moral judgment is nothing more than emotion. We take the view that both emotion and reasoning based on moral values (whether they are articulated as principles, rights, or rules) are essential components for ethics teaching. Increasing acceptance and use of narrative ethics for health professions education40,41 provides a forum for exploration of incorporation of emotions into ethics teaching. Although there are different approaches to narrative ethics, all fundamentally value and engage with narratives to address ethical issues, emphasizing the central role of narratives. Narratives, as open-ended stories from a personal perspective, differ from impersonal constructed case studies commonly used in ethics teaching to illustrate a predetermined ethical concept or principle. Narrative ethics broadens the range of ethical considerations beyond those of a principlist approach in bioethics, facilitating consideration of the people involved, the relationships between them, and, importantly, their feelings. Moreover, narrative ethics in health professions education is a useful means for students to learn about professional identity formation. Our Approach to Narrative Ethics
We have developed an approach to narrative ethics which involves both reasoning and attention to emotion. Our position is that understanding ethical concepts and using them to analyze and reason is vital, but it is not enough on its own. Our narrative ethics pedagogy uses personal life stories of health professionals and their experiences with patients, family members, and colleagues to act as a substrate for ethical reflection and engagement.8,42 This pedagogy is discussed in detail elsewhere, but in brief, we have used this approach in teaching health care ethics in a graduate health professional program over many years. The majority of learners in our program are practicing health care professionals, returning to study for professional development. When using
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this approach in teaching, we specify that the narratives are to be written in the first person about learners’ own experiences. This works to ensure that authors insert themselves into the narrative as well as ensuring that they take ownership of the narrative; for many, this is disquieting and in contrast to the more familiar objective case notes of clinical practice. The focus of the narratives is on everyday ethics and ethically important moments. Learners are asked to reflect and write about an experience that caused them unease or disquiet. We pay attention to both the story itself and the process of producing and engaging with the narrative. To assist storytellers in ethical reflection, we have proposed a series of self-reflective questions43; these include questions such as Why have I chosen to tell this story? How did I decide what to include in and exclude from the story? What is ethically at stake here, and for whom? and, importantly, How has the process of writing this story prompted me to think differently of the event or experience? The analytic process extends to those engaging with the narrative. As we do for the storytellers, we also provide a set of trigger questions for those reading or listening to the story. These trigger questions direct learners’ attention to key elements of the story that may have ethical significance, and lead them through steps of naming, questioning, and considering how the ethical experience in the story could have been otherwise. These trigger questions are classified into three categories: (1) naming questions (e.g., What are the key ethical elements in the story?); (2) sideways-looking questions (e.g., Why is the narrator telling the story in this particular way? What are the key “ethically important moments” in the story?); and (3) forward-looking questions (e.g., What does this story tell us that would not otherwise be heard? How can engaging with this story lead to greater ethical mindfulness in practice?). We suggest that serious, ethically relevant work is involved in the process of answering these questions, which can move learners from initial feelings and intuitions to other ways of seeing the situation and understanding their emotional responses to it. It is a useful means for learners to understand and work through the kind of practitioner they are, and the kind they want to
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become. The aim of this approach is for learners to become ethically mindful and to be capable of ethical thinking and action in practice, rather than being able to produce ethically justifiable decisions about paper-based hypothetical cases. Emotions and Ethical Mindfulness in “The Debriefing”
We have previously described ethical mindfulness and its five key features8,44: (1) being sensitized to ethically important moments in everyday practice, (2) acknowledging the ethically important moments as significant, (3) being able to articulate what is ethically at stake, (4) being reflexive and acknowledging the limitations of one’s standpoint, and finally, (5) being courageous. In light of the relevance of emotions to narrative ethics as described above, we have further developed this notion of ethical mindfulness to better acknowledge and incorporate the important role of emotions. Many personal narratives have significant ethical as well as emotional components, whether they are about the well-recognized “neon-light” life-and-death issues in intensive care, or about more low-key situations in less acute settings, which may appear more mundane but are equally ethically important. Box 1 provides an example of an authentic personal narrative (experienced by L.G.) to illustrate the importance of emotions for ethical mindfulness and ethical practice. We use this example
to illustrate how we would examine these domains within our narrative ethics pedagogy. In a teaching context, learners would be asked to interrogate the narrative using the stated trigger questions. This exercise serves as an excellent starting point for ethical engagement and is a useful lead-in to promoting ethical mindfulness. We examine each of the five key features of ethical mindfulness in turn, which learners would discuss. Being sensitized to ethically important moments in everyday practice First, emotions are often the initial indicator of ethically important moments. Ellie’s situation was obviously going to be emotionally charged and distressing since she was dying. However, what was not acknowledged fully until the debriefing was the importance of the feelings of helplessness, anger, and dread of the health care team. These feelings were not just part of the job that the staff had to deal with; they meant something. Being ethically mindful involves being alert to the everyday emotions that are often put aside because they are to be expected in the context. Acknowledging the ethically important moments as significant The second feature of ethical mindfulness requires acknowledging the ethical significance of the moment and the emotions related to it, and relates to Herman’s38 concept of moral salience.
Box 1 The Debriefinga In my role as clinical ethicist, I was asked to attend and help facilitate discussion at a debriefing on a ward after the death of a young child, Ellie (pseudonym). Ellie had been in intensive care for many weeks, and all the staff—medical, nursing, and allied health—felt that her death had come far too late. Ellie’s mother, a single parent, had aggressively insisted on all possible treatment despite many medical opinions that Ellie’s death was inevitable and close. All those at the debriefing expressed distress in various forms. Some nurses said they felt angry with doctors who agreed to more and more invasive forms of treatment. Others felt angry with Ellie’s mother for wanting this course of treatment, for not being present more often, and for not seeing her child’s suffering, which was obvious to them. One nurse said, “I felt I was torturing her,” and another described how she felt sick in the stomach each morning at the thought that she might be allocated to look after Ellie that day. The doctors expressed feelings of helplessness. One doctor was disturbed by the sense that he had deceived the parents by not correcting their view that Ellie was doing better as some of the medications were reduced. The doctor acknowledged that she believed she had done the right thing, and this was supported by everyone present: The ethical decision to manage the situation this way had already been made in conjunction with the clinical ethics committee. The deceit, such as it was, was regarded as ethically justifiable in these extreme circumstances, as it allowed Ellie’s mother to cope for the short period until it became evident to her that her child was dying, and they agreed to cease ventilation. But the feeling associated with being deceitful remained, a moral residue of the doctor’s ethical valuing of honesty. T his narrative, written by one of the authors (L.G.), is an example of the type of first-person accounts about learners’ own experiences that are written and discussed in the authors’ narrative ethics curriculum. “The Debriefing” is used to examine the importance of emotions for ethical mindfulness and ethical practice.
a
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This is about recognizing that there is something ethically significant going on, rather than it just being a sad situation. As Haidt30 points out, feelings may indicate a moral intuition. This is because ethical principles are not just concepts that people learn; they are values that people care about. If a value that we hold is challenged or under threat, we feel an emotional response. In this situation, the staff cared deeply about Ellie’s well-being and reacted emotionally when they saw her suffer. Being able to articulate what is ethically at stake Third, being ethically mindful means not just acknowledging the ethical significance of the situation and the emotions but also articulating the ethical issues at stake. Here, it is important that students are previously equipped with the appropriate language and ethical knowledge to articulate what is ethically at stake. The staff ’s caring about Ellie’s well-being can be expressed in terms of beneficence and nonmaleficence. The staff ’s distress was not simply distress at Ellie’s suffering or death, understandable and ethically appropriate as this would have been. It was moral distress, the distress felt at being unable to do what is right or being forced to do what is wrong.45 The nurses were feeling that they were doing something wrong to this child (“torture”), which for them was much worse than witnessing suffering that could not be prevented. However, they felt that they had been unable to properly communicate this to the doctors, who, it became evident, were having similar feelings themselves. The issue here was distinguishing between ordinary distress, which could be addressed by support and counseling, and moral distress, which can only be addressed by an acknowledgment of the ethical issues and an ethical rethinking of what is happening. Moral distress permeates clinical practice and is experienced not only in life-ordeath situations but also in many more mundane ones, including pressuring patients to comply with treatments and selectively giving information to patients. Identifying and articulating these emotions requires an understanding of what philosophers call the moral emotions.46 These need to be understood and distinguished from each other. The feeling of moral regret is one example. Moral regret is defined as the feeling
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that can arise when doing something that is prima facie wrong, but ethically justified overall.47 Causing pain or overriding a patient’s wishes in the short term to promote well-being in the long term is a not-uncommon occurrence in health care. One example is restraining a noncompetent patient to administer lifesaving chemotherapy that has known toxic side effects. Even when those doing this task believe it is justified because of the great benefit to the patient, it can cause concern for practitioners because the patient is being coerced and is suffering. These emotions can be understood as moral regret, which in other circumstances would not be ethically justifiable. This is sometimes referred to as “moral residue,”48 although the latter term is used in a number of different ways.49 Moral regret is importantly different from moral distress, which is the feeling arising from being unable to avoid doing something that one believes to be unjustified. Moral distress might occur when those giving the chemotherapy believe it is very unlikely to prolong the patient’s life and will cause more burden than benefit. Distinguishing between moral distress and moral regret is very important. If the emotion is moral distress, this suggests that something unethical may be occurring and should give rise to considerations of how this can be reconsidered so that the treatment plan becomes more ethically appropriate. If it is moral regret, then no change in the treatment plan is needed, and the health professionals involved can seek ways to deal with these difficult feelings without blaming themselves for doing something wrong. Of course, properly distinguishing between the two moral emotions requires practice and integrity, as does ethical practice overall. If it is tempting to let oneself “off the hook,” by deciding that it is moral regret rather than moral distress, this can only be addressed by having the courage of integrity to consider one’s own actions honestly. We suggest that understanding this requires emotional intelligence50 to recognize one’s own emotions and distinguish between different types of emotions clearly enough to be able to communicate with others. Shapiro’s formulations5 would suggest the need for both emotional intelligence and emotional regulation, the former
defined as being aware of emotions and integrating them in practices that lead to positive patient outcomes, while emotional regulation requires modifying what we think to change our emotional responses. If we are doing something that is ethically justified, conceptualizing the emotional reaction as moral residue may assist in regulating the emotion. Being reflexive and acknowledging limitations of one’s standpoint The fourth feature of ethical mindfulness, being reflexive and acknowledging the limitations of our standpoints, involves reflexivity about our own emotions, and acknowledging their source in ourselves and our past experiences. One aspect of this is being willing and able to see the situation from other people’s perspectives. For the health professionals in Ellie’s story, being reflexive would mean acknowledging their intuitions and emotional reactions at the time of the event, and reflecting on their responses. Their emotional responses may relate partly to similar past experiences where things have gone wrong, or they may arise from a single incident which has shaded out other feelings or interpretations. There is nothing unusual or negative in this, but it does require acknowledgment and reflection. Being courageous The final feature of ethical mindfulness is courage, and again, this relates to emotions. Courage has an emotional component itself and is often needed when other emotions, such as fear, are at play. In Ellie’s case, to be ethically mindful would require the health professionals to face their fears: the nurses’ fear of being thought of as criticizing doctors if they spoke up, or doctors’ fears of seeming unprofessional if they acknowledged their feelings of helplessness. In this way, the practitioners involved are presented with the opportunity to consider their own moral identity and assess what kind of practitioner they want to be. We suggest that facing up to our emotions and asking the difficult questions about our moral selves may require courage for a number of reasons. Our emotions may reveal aspects of ourselves of which we are ashamed, or which challenge our sense of identity and self-worth. Having the courage to reflect and act in spite of our fears challenges us to step outside our comfort zone. It may feel easier to suppress or ignore some
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emotions, our own and those of others, but this can cause something important to be missed. Cultivating or slipping into unwarranted emotional detachment is a potential risk to ethical practice. Recommendations and Next Steps
We have argued that emotions should not be ignored or dismissed, because they have a legitimate role in ethics teaching and professional identity formation in health professions education. We propose that using a narrative approach to ethics teaching can be an effective and appropriate way to bring emotions into the formal curriculum. We have offered a reconceptualization of ethical mindfulness that incorporates emotions, recognizing that emotions are embedded in clinical practice. We emphasize the importance of acknowledging and actively addressing emotions to cultivate ethical practice. We suggest that ethics education is a fitting avenue to incorporate emotions, as it provides an appropriate alignment with topics such as professionalism and professional identity formation. We have previously described our experience of using this approach in teaching.43,44 Although we advocate for its use in health professions education, some important considerations should be emphasized. Students need to be provided with the necessary health ethics background knowledge with which they can understand and articulate the ethical issues at stake. A safe and trusting teaching environment must be established and maintained. Emotions can be complex, and potential for emotional harm exists. Students must be given the space and time to engage, which is often difficult in tight curricula. Educators must be appropriately trained and also be emotionally comfortable enough to engage in these kinds of activities. There needs to be an explicit statement of goals and objectives, making clear that this is not just telling stories and evoking emotions for their own sake but, rather, that it is for the purpose of meaningful and serious ethical work. It is also important to incorporate debriefing at the end of the session to ensure that any unresolved issues are addressed. Our experience of using and evaluating narrative ethics to teach ethical mindfulness to health professionals has
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confirmed its value. The added emphasis and focus on emotions potentially deepens the existing emotional engagement and ethical and professional identity work that is accomplished. The challenge with this, and indeed, all health professions teaching is whether it can be successfully translated to actual clinical practice. We believe that this is worthy of exploration. Acknowledgments: The authors are grateful for the helpful comments and suggestions of Dr. Hedy Wald and the anonymous reviewers of this manuscript. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable.
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Teaching and Learning Moments Keeping My Humanity A month into my surgery clerkship, I started a subspecialty rotation. I was assigned to follow a resident on an emergency department consult for an abscess requiring incision and drainage. While the resident was looking through other charts, she asked me to prepare the supplies for this procedure. This was a first for me, but I had some sense of what we needed. I found the iodine solution, bottles of lidocaine, a set of syringes and needles, a scalpel, some gauze, a bottle of saline, and some sterile packing. When I finished, I pulled up a tray with all the supplies that I had gathered. I was missing sterile drapes. Just loud enough for me to hear, the resident said in exasperation: “Can you do anything right on your own? Do I need to hold your hands through every step?” Earlier in my surgery clerkship, during an overnight call, between a laparoscopic cholecystectomy and an appendectomy, I asked my attending for his thoughts about his surgical residency almost 20 years ago. He was approachable and had always appeared to be one of the more laidback surgeons whom I met during the initial weeks of the rotation. He was also a remarkably patient teacher. Thus, I was surprised to hear that, at one point, he had the reputation for being the angriest resident in the hospital. “Surgeons trained in my generation are products of a residency program that was meant to break us down and then rebuild us from scratch as capable, more efficient physicians,” he said. “You were meant to change in the process.” The hours were
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horrendous. On the nights he managed to leave the hospital, he would engage his emergency brakes at every red light in case he fell asleep at the wheel. Making decisions with limited sleep wasn’t easy, but maintaining patience with limited sleep was even more challenging. His attending yelled at him, and, in turn, he yelled at others. He spoke of an environment that fostered a seemingly impossible work ethic, which created the “vintage” surgeon but also bred anger and resentment that could easily spill into one’s personal life. If he had tried harder to “preserve his humanity,” he went on, maybe he wouldn’t have felt like he had to mentally recover from such a dark place. Training conditions have substantially changed in the past couple decades, but, in some ways, the more things change, the more they remain the same. The 120-hour weeks may have fallen by the wayside, but current residents are expected to operate at an efficiency that hadn’t been possible before the advent of electronic medical records. Less time is spent searching for charts or radiographs, yet the abundance of data available requires time to interpret. And the demands during residency for rapid new skill uptake, the feelings of isolation within the daily grind, and not a whole lot of time to connect still provide a large dose of stress. My attending offered a caveat and, in doing so, cultivated my own selfawareness: Regardless of how tough we think we are, we are all vulnerable to being overworked, to the emotional rigors of a difficult case, to mindnumbingly repetitive routines, and to
inefficiencies that can plague hospitals. It is easy to lose our patience, lose our calm, and ultimately lose the person who once channeled idealism into a personal statement for medical school. But even in the most rigorous system, if we can somehow accept the changes that make us a competent physician, while being conscious of and prioritizing the part of us that is patient and empathetic, we do not have to totally abandon who we were at the start of the process. We can keep our humanity. Thinking back on that conversation with my attending, I paused in front of the resident. Before I could react to what she said, I empathized with her instead. I saw an overwhelmed, irritable resident who had lost part of herself. I brushed off her comments and told her not to worry. I would go find the drapes on my own. Shortly thereafter, I prepped the supplies by the patient’s bedside. As we were about to begin the procedure, she smiled and handed me the scalpel. It felt like an apology. I knew I was glimpsing someone who was losing her humanity and just as quickly recovering it. Acknowledgments: The author wishes to thank Dr. Hedy Wald for encouraging him to write about his experiences and for assisting with the editing process. The author also wishes to thank the attending surgeon who shared his experiences so that the author could have a better one. Jason Liu, MS J. Liu is a third-year medical student, Drexel University College of Medicine, Philadelphia, Pennsylvania; e-mail: [email protected].
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Emotions, Narratives, and Ethical Mindfulness Marilys Guillemin, MEd, PhD, and Lynn Gillam, MA, PhD
Abstract Clinical care is laden with emotions, from the perspectives of both clinicians and patients. It is important that emotions are addressed in health professions curricula to ensure that clinicians are humane healers as well as technical experts. Emotions have a valuable and generative role in health professional ethics education. The authors have previously described a narrative ethics pedagogy, the aim of which is to develop ethical mindfulness. Ethical mindfulness is a state of being that acknowledges everyday ethics and ethically important moments as
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linical care is emotionally laden, both for patients and health care professionals. Doctors, nurses, and allied health professionals can and often do feel a range of emotions towards patients and colleagues. These include compassion for patients’ suffering and admiration for their courage, anger at patients who do not look after their own health, and resentment at colleagues perceived to be making poor decisions. Emotional responses in clinical situations can be problematic for students and health practitioners. There is some evidence to suggest that students and junior practitioners feel embarrassed or discomforted by patients’ emotions,1 and sense that if they enter into more than minimal emotional engagement M. Guillemin is professor, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia. L. Gillam is professor, Centre for Health Equity, School of Population and Global Health, University of Melbourne, and academic director, Children’s Bioethics Centre, Royal Children’s Hospital, Melbourne, Victoria, Australia. Correspondence should be addressed to Marilys Guillemin, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Melbourne, Victoria 3010, Australia; telephone: (+61) 3-8344-0827; e-mail: m.guillemin@ unimelb.edu.au. Acad Med. 2015;90:726–731. First published online April 7, 2015 doi: 10.1097/ACM.0000000000000709
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significant in clinical care, with the aim of enabling ethical clinical practice. Using a sample narrative, the authors extend this concept to examine five features of ethical mindfulness as they relate to emotions: (1) being sensitized to emotions in everyday practice, (2) acknowledging and understanding the ways in which emotions are significant in practice, (3) being able to articulate the emotions at play during ethically important moments, (4) being reflexive and acknowledging both the generative aspects and the limitations of emotions, and (5) being courageous.
The process of writing and engaging with narratives can lead to ethical mindfulness, including the capacity to understand and work with emotions. Strategies for productively incorporating emotions in narrative ethics teaching are described. This can be a challenging domain within medical education for both educators and health care students and thus needs to be addressed sensitively and responsibly. The potential benefit of educating health professionals in a way which addresses emotionality in an ethical framework makes the challenges worthwhile.
with patients and families, they will be judged negatively by their seniors. Dealing with this is part of professional identity formation, as junior practitioners must navigate how to handle emotional responses as they negotiate the kind of practitioner they want to become. Whilst emotional engagement with patients and families is recognized by medical educators as essential for good clinical practice2 and as more personally sustainable for doctors than detachment,3,4 this is not necessarily acknowledged or acted on in clinical practice.3
has gained increased prominence over recent decades.9–13 Our experience using this approach in teaching ethics is that students generally become emotionally engaged with the stories, often showing strong emotional responses during their discussion. This triggered our development of the concept of ethical mindfulness to include emotions.
Thus, it is important for health professions education to emphasize understanding and appropriate management of emotions. In this Perspective, we concur with medical educators calling for deeper examination of the role of emotions in health professions education,5,6 including the “emotional process” of becoming a physician.7 We suggest that ethics education is an appropriate place on which to focus, given that ethics teaching already deals with issues of professionalism and professional identity formation, self-care, and practitioner– patient engagement. To demonstrate how this may be achieved, we draw on our previously published work on narrative ethics which uses personal stories to develop ethical mindfulness.8 Narrative ethics is a broad field which
We begin by reviewing current debates on emotions and ethics, focusing on health professions practice and education. We then develop the concept of ethical mindfulness highlighting the relevance of emotions, using a narrative exemplar. We conclude with a discussion of the significance of this approach for health professional ethics education. The Uneasy Place of Emotions in Health Professional Practice and Education
Education in the health professions now routinely incorporates empathy; increasingly, medical curricula aim to promote related attitudes or emotions, in particular compassion and caring.3,14–17 However, learners often receive mixed messages. Emotions are commonly understood to have affective and cognitive components,18 both of which are important for understanding and regulating emotions. Despite this, there is a tendency amongst some medical education researchers to focus on the
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cognitive aspects, explicitly excluding practitioners’ emotional engagement with patients.19–21 This is problematic because the important task of cognitive assessment of affective responses is overlooked when the affective dimensions of health professionals’ responses to patients are not given due attention. Despite evidence that lack of engagement leads to burnout, there are still strong calls for maintaining detachment so as not to compromise clinical judgment or become emotionally fatigued.22–25 As Shapiro5 points out, messages about emotions delivered in the formal curriculum are often contradicted by the informal and hidden curricula, where detachment is exemplified and valorized. Although emotions are at least acknowledged in health professions education, it is our experience in teaching students that the emotions that are more uncomfortable or less socially acceptable, such as anger towards patients or colleagues, receive much less formal attention than, for example, maintaining detachment, though they are equally important. There is a growing literature that highlights the important and productive role of emotions in clinical care and health professions education.26,27 The capacity to engage emotionally has been shown to promote patients’ trust, willingness to communicate, and compliance, whereas detachment can lead to decreased trust and compliance in patients.4,10 Recognition of the inadequacies of the detached clinical version of empathy has prompted revised approaches to empathy in health professions education, such as Halpern’s28 “engaged curiosity,” which reincorporate the affective aspect. The skills required for this type of empathy—namely, selfreflection and the ability to constructively process emotions—are thought to be protective against stress and burnout.28 This suggests that it is both possible and necessary to educate health professionals more thoughtfully about the role of emotions in clinical practice. Emotions and Ethics
In the cognitivist tradition of ethical theory, on which contemporary health care ethics is largely based, emotions have mostly been seen as a disturbance or a threat to ethical practice. Ethical
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practice, commonly understood as ethical decision making, requires rational thought.29 In this standard picture, emotion interferes with reasoning, and hence is a hindrance to ethical decision making30; the process of ethical decision making requires distance from one’s emotions, in order to think clearly and objectively.30 Principlism is the most common foundation for ethics teaching in the health professions.31 Health care students are taught the classic midlevel principles,32 together with the analytic skills to use these principles.33 We suggest that this approach to teaching ethics does not pay sufficient attention to emotions. First, recent work in a number of fields has shown that emotions are not such a threat to reasoning. Klein34 showed how emotions are crucial for intuitive decision making in professional practice in health care and other high-risk occupations. Gigerenzer35 argued that gut feelings could be superior to the rational weighing of gains and possible harms. Although high-intensity emotions may prevent reasonable decisions, emotions of lower intensity are often used as a valuable advisor in decision making.36,37 Second, in ethical theory, emotions have a legitimate and important role, even in the cognitivist/rationalist tradition. In 1985, for example, Herman38 argued that emotions are important for moral sensitivity, which is the capacity to recognize that a situation is morally salient and requires ethical deliberation. Ethically appropriate action is not possible without moral sensitivity, according to Herman.38 More recently, Haidt30 has argued that teaching ethics without reference to emotions fails to prepare students for ethical thinking in the real world, because the real world is emotionally “hot” compared with the classroom. Haidt30 proposes that ethical thinking begins with a moral intuition, which is cognitive, but includes an affective component— namely, a feeling of approval or disapproval. Reasoning follows only if it is elicited by some feature of the situation. Reasoning is most often undertaken with others, such as friends or colleagues, rather than by oneself, and is influenced significantly by their intuitions and emotions. Reasoning can also be influenced by one’s feelings of discomfort
or fear, especially if one’s worldview and values appear to be challenged.30 These insights are significant for health professional ethics education and can be taken into account without adopting the emotivist position, first articulated by Hume,39 that moral judgment is nothing more than emotion. We take the view that both emotion and reasoning based on moral values (whether they are articulated as principles, rights, or rules) are essential components for ethics teaching. Increasing acceptance and use of narrative ethics for health professions education40,41 provides a forum for exploration of incorporation of emotions into ethics teaching. Although there are different approaches to narrative ethics, all fundamentally value and engage with narratives to address ethical issues, emphasizing the central role of narratives. Narratives, as open-ended stories from a personal perspective, differ from impersonal constructed case studies commonly used in ethics teaching to illustrate a predetermined ethical concept or principle. Narrative ethics broadens the range of ethical considerations beyond those of a principlist approach in bioethics, facilitating consideration of the people involved, the relationships between them, and, importantly, their feelings. Moreover, narrative ethics in health professions education is a useful means for students to learn about professional identity formation. Our Approach to Narrative Ethics
We have developed an approach to narrative ethics which involves both reasoning and attention to emotion. Our position is that understanding ethical concepts and using them to analyze and reason is vital, but it is not enough on its own. Our narrative ethics pedagogy uses personal life stories of health professionals and their experiences with patients, family members, and colleagues to act as a substrate for ethical reflection and engagement.8,42 This pedagogy is discussed in detail elsewhere, but in brief, we have used this approach in teaching health care ethics in a graduate health professional program over many years. The majority of learners in our program are practicing health care professionals, returning to study for professional development. When using
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this approach in teaching, we specify that the narratives are to be written in the first person about learners’ own experiences. This works to ensure that authors insert themselves into the narrative as well as ensuring that they take ownership of the narrative; for many, this is disquieting and in contrast to the more familiar objective case notes of clinical practice. The focus of the narratives is on everyday ethics and ethically important moments. Learners are asked to reflect and write about an experience that caused them unease or disquiet. We pay attention to both the story itself and the process of producing and engaging with the narrative. To assist storytellers in ethical reflection, we have proposed a series of self-reflective questions43; these include questions such as Why have I chosen to tell this story? How did I decide what to include in and exclude from the story? What is ethically at stake here, and for whom? and, importantly, How has the process of writing this story prompted me to think differently of the event or experience? The analytic process extends to those engaging with the narrative. As we do for the storytellers, we also provide a set of trigger questions for those reading or listening to the story. These trigger questions direct learners’ attention to key elements of the story that may have ethical significance, and lead them through steps of naming, questioning, and considering how the ethical experience in the story could have been otherwise. These trigger questions are classified into three categories: (1) naming questions (e.g., What are the key ethical elements in the story?); (2) sideways-looking questions (e.g., Why is the narrator telling the story in this particular way? What are the key “ethically important moments” in the story?); and (3) forward-looking questions (e.g., What does this story tell us that would not otherwise be heard? How can engaging with this story lead to greater ethical mindfulness in practice?). We suggest that serious, ethically relevant work is involved in the process of answering these questions, which can move learners from initial feelings and intuitions to other ways of seeing the situation and understanding their emotional responses to it. It is a useful means for learners to understand and work through the kind of practitioner they are, and the kind they want to
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become. The aim of this approach is for learners to become ethically mindful and to be capable of ethical thinking and action in practice, rather than being able to produce ethically justifiable decisions about paper-based hypothetical cases. Emotions and Ethical Mindfulness in “The Debriefing”
We have previously described ethical mindfulness and its five key features8,44: (1) being sensitized to ethically important moments in everyday practice, (2) acknowledging the ethically important moments as significant, (3) being able to articulate what is ethically at stake, (4) being reflexive and acknowledging the limitations of one’s standpoint, and finally, (5) being courageous. In light of the relevance of emotions to narrative ethics as described above, we have further developed this notion of ethical mindfulness to better acknowledge and incorporate the important role of emotions. Many personal narratives have significant ethical as well as emotional components, whether they are about the well-recognized “neon-light” life-and-death issues in intensive care, or about more low-key situations in less acute settings, which may appear more mundane but are equally ethically important. Box 1 provides an example of an authentic personal narrative (experienced by L.G.) to illustrate the importance of emotions for ethical mindfulness and ethical practice. We use this example
to illustrate how we would examine these domains within our narrative ethics pedagogy. In a teaching context, learners would be asked to interrogate the narrative using the stated trigger questions. This exercise serves as an excellent starting point for ethical engagement and is a useful lead-in to promoting ethical mindfulness. We examine each of the five key features of ethical mindfulness in turn, which learners would discuss. Being sensitized to ethically important moments in everyday practice First, emotions are often the initial indicator of ethically important moments. Ellie’s situation was obviously going to be emotionally charged and distressing since she was dying. However, what was not acknowledged fully until the debriefing was the importance of the feelings of helplessness, anger, and dread of the health care team. These feelings were not just part of the job that the staff had to deal with; they meant something. Being ethically mindful involves being alert to the everyday emotions that are often put aside because they are to be expected in the context. Acknowledging the ethically important moments as significant The second feature of ethical mindfulness requires acknowledging the ethical significance of the moment and the emotions related to it, and relates to Herman’s38 concept of moral salience.
Box 1 The Debriefinga In my role as clinical ethicist, I was asked to attend and help facilitate discussion at a debriefing on a ward after the death of a young child, Ellie (pseudonym). Ellie had been in intensive care for many weeks, and all the staff—medical, nursing, and allied health—felt that her death had come far too late. Ellie’s mother, a single parent, had aggressively insisted on all possible treatment despite many medical opinions that Ellie’s death was inevitable and close. All those at the debriefing expressed distress in various forms. Some nurses said they felt angry with doctors who agreed to more and more invasive forms of treatment. Others felt angry with Ellie’s mother for wanting this course of treatment, for not being present more often, and for not seeing her child’s suffering, which was obvious to them. One nurse said, “I felt I was torturing her,” and another described how she felt sick in the stomach each morning at the thought that she might be allocated to look after Ellie that day. The doctors expressed feelings of helplessness. One doctor was disturbed by the sense that he had deceived the parents by not correcting their view that Ellie was doing better as some of the medications were reduced. The doctor acknowledged that she believed she had done the right thing, and this was supported by everyone present: The ethical decision to manage the situation this way had already been made in conjunction with the clinical ethics committee. The deceit, such as it was, was regarded as ethically justifiable in these extreme circumstances, as it allowed Ellie’s mother to cope for the short period until it became evident to her that her child was dying, and they agreed to cease ventilation. But the feeling associated with being deceitful remained, a moral residue of the doctor’s ethical valuing of honesty. T his narrative, written by one of the authors (L.G.), is an example of the type of first-person accounts about learners’ own experiences that are written and discussed in the authors’ narrative ethics curriculum. “The Debriefing” is used to examine the importance of emotions for ethical mindfulness and ethical practice.
a
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This is about recognizing that there is something ethically significant going on, rather than it just being a sad situation. As Haidt30 points out, feelings may indicate a moral intuition. This is because ethical principles are not just concepts that people learn; they are values that people care about. If a value that we hold is challenged or under threat, we feel an emotional response. In this situation, the staff cared deeply about Ellie’s well-being and reacted emotionally when they saw her suffer. Being able to articulate what is ethically at stake Third, being ethically mindful means not just acknowledging the ethical significance of the situation and the emotions but also articulating the ethical issues at stake. Here, it is important that students are previously equipped with the appropriate language and ethical knowledge to articulate what is ethically at stake. The staff ’s caring about Ellie’s well-being can be expressed in terms of beneficence and nonmaleficence. The staff ’s distress was not simply distress at Ellie’s suffering or death, understandable and ethically appropriate as this would have been. It was moral distress, the distress felt at being unable to do what is right or being forced to do what is wrong.45 The nurses were feeling that they were doing something wrong to this child (“torture”), which for them was much worse than witnessing suffering that could not be prevented. However, they felt that they had been unable to properly communicate this to the doctors, who, it became evident, were having similar feelings themselves. The issue here was distinguishing between ordinary distress, which could be addressed by support and counseling, and moral distress, which can only be addressed by an acknowledgment of the ethical issues and an ethical rethinking of what is happening. Moral distress permeates clinical practice and is experienced not only in life-ordeath situations but also in many more mundane ones, including pressuring patients to comply with treatments and selectively giving information to patients. Identifying and articulating these emotions requires an understanding of what philosophers call the moral emotions.46 These need to be understood and distinguished from each other. The feeling of moral regret is one example. Moral regret is defined as the feeling
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that can arise when doing something that is prima facie wrong, but ethically justified overall.47 Causing pain or overriding a patient’s wishes in the short term to promote well-being in the long term is a not-uncommon occurrence in health care. One example is restraining a noncompetent patient to administer lifesaving chemotherapy that has known toxic side effects. Even when those doing this task believe it is justified because of the great benefit to the patient, it can cause concern for practitioners because the patient is being coerced and is suffering. These emotions can be understood as moral regret, which in other circumstances would not be ethically justifiable. This is sometimes referred to as “moral residue,”48 although the latter term is used in a number of different ways.49 Moral regret is importantly different from moral distress, which is the feeling arising from being unable to avoid doing something that one believes to be unjustified. Moral distress might occur when those giving the chemotherapy believe it is very unlikely to prolong the patient’s life and will cause more burden than benefit. Distinguishing between moral distress and moral regret is very important. If the emotion is moral distress, this suggests that something unethical may be occurring and should give rise to considerations of how this can be reconsidered so that the treatment plan becomes more ethically appropriate. If it is moral regret, then no change in the treatment plan is needed, and the health professionals involved can seek ways to deal with these difficult feelings without blaming themselves for doing something wrong. Of course, properly distinguishing between the two moral emotions requires practice and integrity, as does ethical practice overall. If it is tempting to let oneself “off the hook,” by deciding that it is moral regret rather than moral distress, this can only be addressed by having the courage of integrity to consider one’s own actions honestly. We suggest that understanding this requires emotional intelligence50 to recognize one’s own emotions and distinguish between different types of emotions clearly enough to be able to communicate with others. Shapiro’s formulations5 would suggest the need for both emotional intelligence and emotional regulation, the former
defined as being aware of emotions and integrating them in practices that lead to positive patient outcomes, while emotional regulation requires modifying what we think to change our emotional responses. If we are doing something that is ethically justified, conceptualizing the emotional reaction as moral residue may assist in regulating the emotion. Being reflexive and acknowledging limitations of one’s standpoint The fourth feature of ethical mindfulness, being reflexive and acknowledging the limitations of our standpoints, involves reflexivity about our own emotions, and acknowledging their source in ourselves and our past experiences. One aspect of this is being willing and able to see the situation from other people’s perspectives. For the health professionals in Ellie’s story, being reflexive would mean acknowledging their intuitions and emotional reactions at the time of the event, and reflecting on their responses. Their emotional responses may relate partly to similar past experiences where things have gone wrong, or they may arise from a single incident which has shaded out other feelings or interpretations. There is nothing unusual or negative in this, but it does require acknowledgment and reflection. Being courageous The final feature of ethical mindfulness is courage, and again, this relates to emotions. Courage has an emotional component itself and is often needed when other emotions, such as fear, are at play. In Ellie’s case, to be ethically mindful would require the health professionals to face their fears: the nurses’ fear of being thought of as criticizing doctors if they spoke up, or doctors’ fears of seeming unprofessional if they acknowledged their feelings of helplessness. In this way, the practitioners involved are presented with the opportunity to consider their own moral identity and assess what kind of practitioner they want to be. We suggest that facing up to our emotions and asking the difficult questions about our moral selves may require courage for a number of reasons. Our emotions may reveal aspects of ourselves of which we are ashamed, or which challenge our sense of identity and self-worth. Having the courage to reflect and act in spite of our fears challenges us to step outside our comfort zone. It may feel easier to suppress or ignore some
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emotions, our own and those of others, but this can cause something important to be missed. Cultivating or slipping into unwarranted emotional detachment is a potential risk to ethical practice. Recommendations and Next Steps
We have argued that emotions should not be ignored or dismissed, because they have a legitimate role in ethics teaching and professional identity formation in health professions education. We propose that using a narrative approach to ethics teaching can be an effective and appropriate way to bring emotions into the formal curriculum. We have offered a reconceptualization of ethical mindfulness that incorporates emotions, recognizing that emotions are embedded in clinical practice. We emphasize the importance of acknowledging and actively addressing emotions to cultivate ethical practice. We suggest that ethics education is a fitting avenue to incorporate emotions, as it provides an appropriate alignment with topics such as professionalism and professional identity formation. We have previously described our experience of using this approach in teaching.43,44 Although we advocate for its use in health professions education, some important considerations should be emphasized. Students need to be provided with the necessary health ethics background knowledge with which they can understand and articulate the ethical issues at stake. A safe and trusting teaching environment must be established and maintained. Emotions can be complex, and potential for emotional harm exists. Students must be given the space and time to engage, which is often difficult in tight curricula. Educators must be appropriately trained and also be emotionally comfortable enough to engage in these kinds of activities. There needs to be an explicit statement of goals and objectives, making clear that this is not just telling stories and evoking emotions for their own sake but, rather, that it is for the purpose of meaningful and serious ethical work. It is also important to incorporate debriefing at the end of the session to ensure that any unresolved issues are addressed. Our experience of using and evaluating narrative ethics to teach ethical mindfulness to health professionals has
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confirmed its value. The added emphasis and focus on emotions potentially deepens the existing emotional engagement and ethical and professional identity work that is accomplished. The challenge with this, and indeed, all health professions teaching is whether it can be successfully translated to actual clinical practice. We believe that this is worthy of exploration. Acknowledgments: The authors are grateful for the helpful comments and suggestions of Dr. Hedy Wald and the anonymous reviewers of this manuscript. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable.
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Perspective 37 Zinn JO. Heading into the unknown: Everyday strategies for managing risk and uncertainty. Health Risk Soc. 2008;10:439–450. 38 Herman B. The practice of moral judgment. J Philos. 1985;82:414–443. 39 Karlsson MM. 2006. Reason, passion, and the influencing motives of the will. In: Traiger S, ed. The Blackwell Guide to Hume’s Treatise. Oxford, UK: Blackwell Publishing Ltd., Oxford; 2006. 40 Charon R. Narrative Medicine: Honoring the Stories of Illness. New York, NY: Oxford University Press; 2006. 41 Goodrich TJ, Irvine CA, Boccher-Lattimore D. Narrative ethics as collaboration: A four-session curriculum. Fam Syst Health. 2005;23:348. 42 Guillemin M, Gillam L. Ethical mindfulness: Narrative analysis and
everyday ethics in health care. In: Rothman BK, Armstrong EM, Tiger R, eds. Bioethical Issues, Sociological Perspectives, Vol 9 (Advances in Medical Sociology). Oxford, UK: JAI Press; 2008:157–178. 43 Guillemin M, McDougall R, Gillam L. Developing “ethical mindfulness” in continuing professional development in healthcare: Use of a personal narrative approach. Camb Q Healthc Ethics. 2009;18:197–208. 44 Gillam L, Delany C, Guillemin M, Warmington S. The role of emotions in health professional ethics teaching. J Med Ethics. 2014;40:331–335. 45 Pauly BM, Varcoe C, Storch J. Framing the issues: Moral distress in health care. HEC Forum. 2012;24:1–11.
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Teaching and Learning Moments Keeping My Humanity A month into my surgery clerkship, I started a subspecialty rotation. I was assigned to follow a resident on an emergency department consult for an abscess requiring incision and drainage. While the resident was looking through other charts, she asked me to prepare the supplies for this procedure. This was a first for me, but I had some sense of what we needed. I found the iodine solution, bottles of lidocaine, a set of syringes and needles, a scalpel, some gauze, a bottle of saline, and some sterile packing. When I finished, I pulled up a tray with all the supplies that I had gathered. I was missing sterile drapes. Just loud enough for me to hear, the resident said in exasperation: “Can you do anything right on your own? Do I need to hold your hands through every step?” Earlier in my surgery clerkship, during an overnight call, between a laparoscopic cholecystectomy and an appendectomy, I asked my attending for his thoughts about his surgical residency almost 20 years ago. He was approachable and had always appeared to be one of the more laidback surgeons whom I met during the initial weeks of the rotation. He was also a remarkably patient teacher. Thus, I was surprised to hear that, at one point, he had the reputation for being the angriest resident in the hospital. “Surgeons trained in my generation are products of a residency program that was meant to break us down and then rebuild us from scratch as capable, more efficient physicians,” he said. “You were meant to change in the process.” The hours were
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horrendous. On the nights he managed to leave the hospital, he would engage his emergency brakes at every red light in case he fell asleep at the wheel. Making decisions with limited sleep wasn’t easy, but maintaining patience with limited sleep was even more challenging. His attending yelled at him, and, in turn, he yelled at others. He spoke of an environment that fostered a seemingly impossible work ethic, which created the “vintage” surgeon but also bred anger and resentment that could easily spill into one’s personal life. If he had tried harder to “preserve his humanity,” he went on, maybe he wouldn’t have felt like he had to mentally recover from such a dark place. Training conditions have substantially changed in the past couple decades, but, in some ways, the more things change, the more they remain the same. The 120-hour weeks may have fallen by the wayside, but current residents are expected to operate at an efficiency that hadn’t been possible before the advent of electronic medical records. Less time is spent searching for charts or radiographs, yet the abundance of data available requires time to interpret. And the demands during residency for rapid new skill uptake, the feelings of isolation within the daily grind, and not a whole lot of time to connect still provide a large dose of stress. My attending offered a caveat and, in doing so, cultivated my own selfawareness: Regardless of how tough we think we are, we are all vulnerable to being overworked, to the emotional rigors of a difficult case, to mindnumbingly repetitive routines, and to
inefficiencies that can plague hospitals. It is easy to lose our patience, lose our calm, and ultimately lose the person who once channeled idealism into a personal statement for medical school. But even in the most rigorous system, if we can somehow accept the changes that make us a competent physician, while being conscious of and prioritizing the part of us that is patient and empathetic, we do not have to totally abandon who we were at the start of the process. We can keep our humanity. Thinking back on that conversation with my attending, I paused in front of the resident. Before I could react to what she said, I empathized with her instead. I saw an overwhelmed, irritable resident who had lost part of herself. I brushed off her comments and told her not to worry. I would go find the drapes on my own. Shortly thereafter, I prepped the supplies by the patient’s bedside. As we were about to begin the procedure, she smiled and handed me the scalpel. It felt like an apology. I knew I was glimpsing someone who was losing her humanity and just as quickly recovering it. Acknowledgments: The author wishes to thank Dr. Hedy Wald for encouraging him to write about his experiences and for assisting with the editing process. The author also wishes to thank the attending surgeon who shared his experiences so that the author could have a better one. Jason Liu, MS J. Liu is a third-year medical student, Drexel University College of Medicine, Philadelphia, Pennsylvania; e-mail: [email protected].
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