Out of Hours Increasing emotional support for healthcare workers can rebalance clinical detachment and

Healthcare professionals are confronted with patients’ emotional traumas such as , , and on a daily, if “At their extremes, true empathy and clinical detachment not hourly, basis. Faced with this kind of hold potential for … progression to distress, we might exhibit (and experience) what I will call ‘true empathy.’ This kind of or a generalised emotional detachment … both viewed as empathy involves another’s components of burnout …” oneself as an ‘emotional resonance’, rather than just correctly acknowledging them.1 Alternatively, we may exercise ‘clinical detachment’, a conscious choice to numb extreme, while retaining some of the the finding that medical students at Ulm ourselves to emotional resonance with benefits of each approach. Unfortunately, University reported decreased empathy as our patients in order to maintain scientific modern medicine is heavily skewed towards their dissection course progressed5 may objectivity, and to help us cope, to carry on clinical detachment (Figure 1). in fact represent their having acquired the for the benefit of the next patient in line. skill of clinical detachment.6 Although true empathy and clinical CLINICAL DETACHMENT AS THE The realities of today’s clinical arena detachment must be mutually exclusive DEFAULT similarly drive us towards clinical in their purest forms, the choice between Ever since William Hunter, an 18th century detachment as the default. Rapid scientific them is a false dichotomy. For the majority surgeon–anatomist, suggested that his progress has produced modern diagnostic of clinicians, their response to emotional students should acquire ‘a necessary and therapeutic options that are steeped in trauma will lie somewhere between the inhumanity’ through dissection,3 an technical data and challenging procedures, two, held in an uncomfortable equilibrium of ‘clinical detachment’ as all of which need to be managed by clear- governed by cultural or institutional belief systems and competing doctor and patient the appropriate disposition has become thinking clinician-scientists. Now more agendas. At their extremes, true empathy pervasive. Sir William Osler, widely viewed than ever, the idea of clinical detachment as 7 and clinical detachment hold potential as the father of modern medicine, said in his a prerequisite for scientific objectivity will 4 for unintended progression to emotional 1912 essay Aequanimitas that, ‘A rare and ring true for health workers. This mindset exhaustion or a generalised emotional precious gift is the art of detachment’ and may also be reinforced by the immense detachment, respectively, both viewed as argued that doctors might objectively ‘see workloads, time pressures, and target- components of burnout, a problem affecting into’ a patient’s ‘inner life’ by neutralising driven cultures of many health systems, as many as 58% of medical residents (junior their emotions to the point that they feel factors that would make clinicians more doctors).2 nothing in response to .1 Further, likely to choose the short-term Therefore, the ideal response to emotional Hunter’s original view of the dissection benefits of detachment over the patient- trauma might be an exact balance between room as a training ground for developing centred benefits of true empathy (Figure 1). true empathy and clinical detachment, clinical detachment has persisted into Finally, we often lack the tools to interpret minimising the risks associated with either the 21st century. Hildebrandt notes that troubling emotions, or we do not believe

Figure 1. A response to patient emotional trauma skewed towards clinical detachment may drive long-term progression to generalised emotional detachment and burnout.

Patient-centred Patients’ emotional trauma Clinician-centred For example, grief, , anger, and Increased doctor–patient loneliness Scientific objectivity Increased therapeutic adherence Short-term coping

True empathy, with Clinical detachment emotional resonance

Generalised Emotional exhaustion emotional detachment

Burnout

376 British Journal of General Practice, July 2016 Patient-centred Patients’ emotional trauma Clinician-centred For example, grief, pain, anger, and Increased doctor–patient trust loneliness Scientific objectivity Increased therapeutic adherence Short-term coping

True empathy, with Clinical detachment emotional resonance

Generalised Emotional exhaustion emotional detachment • Reflective practice • Clinical supervision • Peer support • Schwartz rounds Burnout

Figure 2. A range of supportive interventions can reduce the likelihood of emotional resonance progressing to emotional exhaustion, allowing balance between true empathy and clinical detachment to be restored. ourselves capable of doing so, meaning that ADDRESS FOR CORRESPONDENCE we opt instead for a predominantly detached response. This real or perceived inability to Luke Austen Harris Manchester College, Mansfield Road, Oxford process emotional resonance is the most OX1 3TD, UK. important driver of our over-detachment E-mail: [email protected] because it is the most amenable to change. By promoting strategies to better interpret emotional resonance arising from patients’ ‘We can’t selectively numb … traumas, we can provide a buffer, facilitating Numb the dark and you numb the light.’’9 a shift back towards the ideal balance of true empathy and clinical detachment For healthcare workers, this means that, (Figure 2). as the weeks of gruelling work blur into months and years, clinical detachment may A SHIFT TOWARDS TRUE EMPATHY lead to numbing not only the emotions One particularly promising way of supporting of our patients, but also the emotional healthcare staff is the implementation REFERENCES resonance of colleagues, friends, and those of Schwartz Centre Rounds®, monthly 1. Halpern J. What is clinical empathy?J Gen we most. Intern Med 2003; 18(8): 670–674. multidisciplinary meetings focused on The need to end the age of clinical 2. Pereira-Lima K, Loureiro SR. Burnout, , discussing the emotional and social aspects detachment is urgent. If we act now to , and social skills in medical of health work. These 1-hour sessions residents. Psychol Health Med 2015; 20(3): increase emotional support for healthcare involve the presentation of a case study and 353–362. staff, we can rewrite medicine’s discussion of the emotional issues it raised, 3. Richardson R. A necessary inhumanity? Med psychological rules of engagement for years followed by time for questions, reflection, Humanit 2000; 26(2): 104–106. to come. and the sharing of similar experiences, led 4. Osler W. Aequanimitas. Ravenio Books, 1927. 8 5. Böckers A, Jerg-Bretzke L, Lamp C,et al. by a trained facilitator. A 2012 qualitative Luke Austen, The gross anatomy course: an analysis of its analysis of the rounds in two UK pilot sites Fourth-year medical student, Harris Manchester importance. Anat Sci Educ 2010; 3(1): 3–11. suggested that rounds increased respect, College, University of Oxford, Oxford. 6. Hildebrandt S. Developing empathy and clinical understanding, and empathy between detachment during the dissection course in DOI: 10.3399/bjgp16X685957 staff,8 a benefit that consultant psychologist gross anatomy. Anat Sci Educ 2010; 3(4): 216; Leslie Morrison says is beginning to be author reply 217. shown to ‘spill over into a greater sense of 7. Coulehan J, Granek IA. Commentary: ‘I I’ll and empathy for patients’. continue to grow’: rubrics and reflective writing in medical education. Acad Med 2012; 87(1): Better emotional support for healthcare 8–10. workers can offer the foundations for 8. Goodrich J. Supporting hospital staff to provide medicine to shift towards true empathy and compassionate care: do Schwartz Center away from clinical detachment. Despite the Rounds work in English hospitals? J R Soc Med short-term benefits, the long-term harms 2012; 105(3): 117–122. of detachment may be profound. 9. Brown B. Daring greatly: how the to be vulnerable transforms the way we live, love, In her bestselling book Daring Greatly, parent, and lead. London: Penguin Life, 2015. Professor Brené Brown argues that:

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