A consultant and her junior sit opposite the daughter of a dying patient. They have entered the relatives’ room following an assessment of the patient on the ward round. The elderly lady is clearly succumbing to pneumonia, and the consultant wants to explain why continued efforts to ventilate non-invasively through a mask and monitor intensely in the high dependency unit are probably not the right things to do. The conversation lasts 15 minutes, for the patient’s daughter finds it hard to understand why such aggressive approaches to treatment should not continue. But already it has been going on for four days, and the situation is only got worse.
‘I’m sorry Mrs Davis, I really think it’s time for us to be honest with you, honest with the patient and with ourselves, and to admit that everything we have done, the antibiotics, the blood tests, the mask, have not made a difference. She’s getting anxious and distressed, and the truth that we must accept that this pneumonia is too much for her.’
‘But she has got through this type of illness before.’
‘I think this really is worse. And that was five years ago…her heart and lungs have grown weaker since then. We really are just keeping her going, keeping her alive, artificially really. The chances of her improving are next to zero now.’
‘But she improved at the beginning…’
‘She did. She tried, we tried, if there was a chance she would have taken it by now. I’m glad we tried as hard as we did, even if there was a 2, 3, 5 percent chance, it was worth it. But now it has become clear…I’m sorry.’
The relative begins to cry. The junior doctor watches as his consultant reaches to the desk for a box of tissues. She puts a hand on the relative’s hand, where it rests on the edge of her seat, and she offers one of the tissues. She takes her time, gives enough space for the daughter to gather herself, but then carries on, without being brutal. The relative seems to understand, and agrees. It’s not a case of bulldozing her, just allowing her to take in the truth of the situation. The junior doctor watches in some awe, impressed by his consultant’s skill, her ability to empathise, to adjust her tone, to choose just the right words. He decides to emulate her, and to develop the skills that he was observed.
They leave relatives’ room. The patient’s daughter remains there, teary eyed, fiddling with her mobile phone. Consultant and junior walk back to the nurses’ station, where the patient’s notes lay open.
‘You couldn’t get me a continuation sheet could you? I need to write it all down, the usual essay! God…the poor thing never had a chance, I don’t know why we’ve carried on so long. Ten years ago she wouldn’t have even been offered non-invasive ventilation…we probably use it too much to be honest…’
Her junior is shocked. He gets the paper, places it into the notes, and watches as his boss writes a version of the discussion down. All those fine words…
What has happened here? Did the consultant actually mean what she said. Was she lying? Is she completely two-faced? Or was she just acting – playing the part? And playing it so well! Was she compassionate? Yes, it looks as though she was. So was she lying and practising compassionately at the same time? It seems so.
Ups and downs
Any non-medically trained person following a typical ward round in an acute hospital would be shocked at the range of emotions that is displayed and experienced. A ward round involves giving good news to those who are recovering, and the worst imaginable to those diagnosed with terminal disease. There are conversations with relatives regarding end of life care, and delicate explorations of what patients would have wanted in the final days and weeks of life.
The doctors involved engage all of their interpersonal skills, including empathy, delicacy, subtlety and sometimes assertiveness. Additionally they maintain an awareness of how the team is working. There will be teaching, cold facts and figures provided by their warm blooded patients providing the raw material, and there will be humour, which promotes good feeling between colleagues. When the mood turns jocular the dark cloud that hovered above them (following, say, a discussion with a patient about their cancer diagnosis), dissipates in an instant.
So many juxtapositions. Such inconsistency. Do we mean any of it?
The ability to be emotionally nimble is crucial in medicine. That’s because the typical day wil involve numerous human situations, to which the doctor must adapt quickly. She must sense the timing of the situation and change their demeanour, their behaviour and the choice of words accordingly. It is not somuch the need to be a comedian as to absorb, reflect and then take the lead according to the feelings that have been experienced. For, in critical or emotionally demanding situations, all will be looking to the doctor for their contributions and their judgement as to how to proceed.
So this leads onto the question, are doctors the supreme actors? And are they professionally insincere?
This article is, of course, written from the point of view of a health care practitioner. One could argue that this is the wrong way round, and that sincerity needs to be confirmed from the patient’s point of view. Certainly, if a doctor fails in making an accurate assessment of an emotionally charged situation, and adopts the wrong tone, they will come across as insincere. He will fail. The successful doctor will always appear sincere, but the question is – does it really matter if they believe, and feel, what they are saying? After all, surely it is the end result, and the effect that the words have on a patient or family, that really matters, not the true quality of emotions within.
Two kinds of acting
Raj Persaud wrote a brief and entertaining article for BMJ Careers – ‘Faking it’. He explained that…
Psychologists use the term “surface level emotional labour” to capture the fact that a large part of dealing with people at work is basically “faking it” or displaying emotions we don’t actually feel, like feigning interest, sympathy, or understanding.
One of his references is an internet accessible paper by C´eleste Brotheridge and Alicia Grandey, ‘Emotional Labor and Burnout: Comparing Two Perspectives of “People Work”’ (2002). In this, the relationship between those types of acting (be they voluntary or involuntary) are related to the preservation of mental wellbeing in people who work in ‘service industries’. Medicine features prominently in it. They explain acting in more detail:
(NB – for ‘customers’ read ‘patients’!)
In surface acting, employees modify and control their emotional expressions. For example, employees may enhance or fake a smile when in a bad mood or interacting with a difficult customer. The inauthenticity of this surface-level process, showing expressions discrepant from feelings, is related to stress outcomes due to the internal tension and the physiological effort of suppressing true feelings.
…inauthentic [acting] over time may result in feeling detached not only from one’s true feelings but also from other people’s feelings, suggesting a relationship with the dimension of depersonalization. Feeling diminished personal accomplishment is also likely if the employee believes that the displays were not efficacious or were met with annoyance by customers. Thus, surface acting is expected to relate to all three dimensions of burnout.
Deep acting is the process of controlling internal thoughts and feelings to meet the mandated display rules. Emotions involve physiological arousal and cognitions, and deep acting works on modifying arousal or cognitions through a variety of techniques.
…doing “emotion work” was a way of decreasing a state of emotional dissonance and may also result in a feeling of accomplishment if the performance is effective. Thus, deep acting might not relate to emotional exhaustion because it minimizes the tension of dissonance.
Another accessible article, ‘Reassessing the concept of emotional labour in student nurse education: role of link lecturers and mentors in a time of change’ by Pam Smith and Benjamin Gray (Nursing Education Today, 2000), explores these specifically in relation to healthcare. They cite Arlie Hochschild, author of ‘The Managed Heart’ (University of California Press, Berkeley, 1983), which seems to form the basis of most studies into how we modulate our emotions in the workplace.
Defining emotional labour Hochschild suggests that emotional labour involves the induction or suppression of feeling in order to sustain an outward appearance that produces in others a sense of being cared for in a convivial safe place.
The idea of ‘emotional labour’ really does chime, for most healthcare professionals would agree that emotional exhaustion precedes physical exhaustion during a busy shift. Just the other day I said to a colleague, ‘I’ve had three DNAR discussions on this ward round, I don’t think I can manage another right now.’ But, just as superficial acting is associated with ‘burnout’ (a paradoxical and counterintuitive findings one might think), deep acting appears to lead to true ‘job satisfaction’. This also rings true. You really feel you’ve done some good when you dip into a person’s difficult life, make a significant intervention, and then leave them. That is medicine. The satisfaction negates the exhaustion. It is ‘dissonance’ that wears you down.
Smith and Gray also note,
By brushing over the emotional labour of nurses as an essential skill that does not require development, because it is so ‘basic’, the techniques of nurses’ emotional labour go unappreciated and are not developed as resources for the National Health Service (NHS) to draw upon.
This is a valuable comment. What seems like an ‘obvious’ element of compassionate healthcare is in fact a resource, one that is not infinite. A highly relevant point in the current climate of criticism.
An emotional continuum
We act. I think we can accept that as a given. It’s part of our professional skill set. I am more interested in how this affects our ability to provide compassionate care. My suggestion, and I would love to know what others think about this, is that rather than flipping between a mere two levels of acting and involvement, we move steadily along a continuum, like whales plumbing the ocean depths, responding to our perception of how emotionally complex and ethically demanding each situation is. I can only speak for myself, but I think the ‘emotional work’ that I commit to is in direct proportion to those quotients. The expression of compassion is, in turn, directly related to that commitment, the words and actions being fuelled by a rarer and more precious fuel. The rewards however, are all the greater, as noted above. To put it simply, ‘you get out what you put in’… but it is unrealistic to put in your all during every interaction.
So, what of our consultant, the one who said all the right things and then displayed a streak of cynicism to her junior a minute later? I think I understand her. She had become too nimble, too smooth, too adept at making the quick change in emotional depth. She, the consummate actor, found it too easy to flit between compassionate caregiver and amusing educator. However sincere her words to the patient’s daughter, the rapid alteration in tone belied her.