Although the study of medicine and the tradition of medical students gaining clinical experience on hospital wards have not significantly changed over the years, the experience of physicians practicing in the current climate has changed dramatically. Physicians are confronted with increasing regulations aimed at improving quality of care and are often overwhelmed by their position in a tug-of-war between administrators, staff, colleagues and most importantly, patients. With more than half of the US physicians experiencing professional burnout, questions arise regarding their mental health and work-life balance. Blendon et al reported an overall decline in the public’s confidence and trust in physicians, which may be explained by cultural changes as well as displeasure with medical leaders’ responses to healthcare needs. As the next generation of physicians emerges in this evolving healthcare environment, adaptation to new practices and regulations will be imperative. Emotional intelligence (EI) and mindfulness provide a possible solution to the struggles physicians will invariably face.
The term EI, which refers to a person’s ability to recognise, discriminate and label their own emotions and those of others, was coined by Salovey and Mayer and popularised by Goleman.[2,3] Mindfulness is the process by which an individual actively observes his or her thoughts and feelings without judgement. With foundations in Eastern meditation, mindfulness is now an accepted method of stress reduction in Western culture.
The practice and employment of synergistic EI and mindfulness is grossly lacking from medical school curricula, postgraduate training and continuing medical education (CME) programmes. The systemic deficiency of both EI and mindfulness in healthcare has become more apparent as studies have demonstrated high burnout rates, increasing public mistrust in physicians and disheartening data indicating that 300–400 physicians commit suicide each year; a surprising figure that equals approximately one physician per day.
Identifying a patient’s primary emotion and conveying empathy in the staged, standardised patient settings found commonly in medical education are helpful but not entirely accurate tests of one’s EI and are insufficient for the modern physician. EI and mindfulness are tested most aptly during the trainwreck situations that are not uncommon in healthcare settings. These are the moments in which the patient is acutely deteriorating, the nurses and staff are overworked and unhappy and the patient’s frightened family members are gathered around the room. Here, the physician is required to both identify and adapt to the intense emotions of all parties involved and respond to these emotions in an appropriate manner. However, some may argue in favour of managing the task or crisis at hand rather than the people involved in the particular event. Effective physicians, like effective politicians, businessmen and academics, who subscribe to the notion of separating people from tasks, could perhaps be more effective if they routinely incorporate EI into problem solving. Moreover, focus should be shifted to training physicians to understand their own personalities. Personalities certainly vary among physicians, but physicians with insight into their own EI may cater their interactions to patients by acknowledging their own pre-existing personality traits. Therefore, different personality types may be able to navigate similar situations in disparate but successful fashions. A physician with EI and mindfulness training will be able to do this successfully while still acknowledging their own emotional reactions to this difficult situation.
Physician performance is influenced by interactions with the system as a whole. Therefore, medical schools, residency programmes and CME programmes should enhance existing curricula with EI courses and mindfulness training. EI combined with mindfulness must be taught from the beginning of medical school in anticipation of the realities that students will undoubtedly face as they advance to clinical years. Junior medical students are generally required to take a course that prepares them for scenarios that they may encounter in their upcoming clinical rotations and clinical medicine. As described earlier, this course usually employs actors portraying standardised patients with an illness and often an underlying emotional issue that must also be addressed. Theoretically, the concept is quite practical; however, it does not adequately prepare the student for enough aspects of clinical reality. The reality sometimes unbeknownst to new doctors can be found in, for example, the situation a new resident faces while delivering bad news to a real patient. A hysterical family member in the background or a dispute among family members about treatment options may be unaccounted for in medical school scenarios. Unlike the staged situation where predictability prevails, newly graduated doctors are often thrust into emotionally laden, high stakes interactions with patients and family members, nurses, staff and sometimes colleagues. Early immersion through shadowing and mentorship programmes could better prepare students for what lies ahead in the real clinical environment.
With the proper training, medical students could learn how to effectively deal with these challenges in an emotionally intelligent manner. Dobkin and Hutchinson suggested that mindfulness training was useful for medical and dental students; however, there were many unanswered questions with respect to the timing of training in the trajectory of the physician’s career. Residency training programmes have undoubtedly changed in recent times with Accreditation Council for Graduate Medical Education regulations on work hours and an increased focus on resident health. Nevertheless, more specific strategies are required to promote mental health.
The current climate in medicine, rife with regulation and litigation, encourages physicians to behave less as healers and more as salesmen with the patients as their customers and administrators assuming the roles of bosses. Medical students and residents, immersed in the process of learning how to doctor, are sometimes naïve and unaware of the post-training responsibilities required in real-world practice. In addition to taking care of patients, physicians are required to run their practices, paying attention to billing and collections, management of staff and maintaining licensures. Although physicians contend with these responsibilities and duties mandated by the system, EI and mindfulness continue to be underemphasised.
In following the unwritten rule that the customer is always right, physicians are begrudgingly thrust into a vulnerable role. Furthermore, modern physicians in the USA find themselves pressured to comply with policies that have no evidence base as hospitals maintain accreditations or Press-Ganey scores at any cost. Simultaneously, physicians must interact with potentially unhappy colleagues, dissatisfied staff and patients who may feel they do not get enough physician contact. EI and mindfulness strategies that emphasise conflict management and self-compassion should be taught formally within leadership courses and CME offerings to support the practicing physician in navigating this difficult environment.
Ambady and Rosenthal discovered that when people watched 30 s soundless clips of real physician-patient interactions, their judgements of the physician’s kindness predicted whether that physician would be sued rather than the outcome of the procedure or care. To further touch on the litigious climate of medicine, Robbennolt has suggested that many physicians have not been trained effectively in communicating with patients, especially with regard to apologising after making mistakes, thus leading to potential malpractice suits. Of course, physician hubris is not the sole factor in malpractice suits and some adverse events merit litigation. Physicians still struggle though, coping with denial and having difficulty acknowledging their errors like any lay person may. A paradigm shift might better prepare the physician for some of the difficulties he or she will undoubtedly encounter. What should differentiate physicians from the public, aside from the medical knowledge they have been privileged to garner through years of schooling, is EI and the employment of mindfulness strategies. The combination of these attributes may enable physicians to better realise what factors may be in or out of their control in addition to more effectively communicating possible mistakes made. Furthermore, EI and mindfulness provide physicians with one technique, among many others, which can aid in handling truly stressful moments.
Techniques employed by physicians to contend with overwhelming feelings of anxiety are not limited to EI and mindfulness. Self-compassion and stress inoculation training are examples of two other strategies that can certainly enhance medical education. Neff has described self-compassion as ‘perceiving one’s experiences as part of the larger human experience rather than seeing them as separating and isolating’. She goes on to define it as having ‘an emotionally positive self-attitude that should protect against the negative consequences of self-judgement, isolation and rumination’. Stress inoculation training is a form of cognitive behavioural therapy that can serve as a preventative strategy by preparing individuals and/or exposing them to stressful situations so that they may develop familiarity and ultimately ‘resistance’ to certain stressors. In addition to both EI and mindfulness, these two methods may serve as tools in the modern physicians’ armamentarium. Physicians must understand that they assume an inherent burden that may not be entirely understood by everyone around them. Any of the potential stressors that accompany being a physician, specifically fatigue coupled with the overarching responsibility of caring for a sick human being are not experienced by all members of the healthcare team. This further highlights the need for increased EI and mindfulness training. Nurses and other hospital employees may encounter a less than approachable and short-tempered physician poorly coping with fatigue and other stressors. Adding to the workloads and stress borne by modern physicians are non-patient care tasks that are painstakingly time-consuming. In American medical practice, it has been shown that for every hour physicians provide direct clinical face-time to patients, nearly 2 additional hours are spent on documentation and desk work within the clinic day. Outside actual office hours, physicians spend another 1–2 hours of personal time each night doing additional computer and other clerical work.
The importance of maintaining mindfulness while being overworked should be impressed on medical students, residents and physicians. Unfortunately, a paucity of sufficient coping mechanisms and physicians’ oblivion to their emotional states and reactions leads to tenuous relationships with peers that should be avoidable.
The physician is looked on as the leader of the healthcare team, thus making the roles of EI and mindfulness integral for his or her leadership success. As Mayer points out, ‘EI, however, is not agreeableness. It is not optimism. It is not happiness. It is not calmness. It is not motivation. Such qualities, although important, have little to do with intelligence, little to do with emotions and nearly nothing to do with actual EI.’ The EI and mindfulness attributes required of a physician in a critical situation are the ability to sense the impending panic and potential fear of the other people involved and react appropriately along with recognising their own emotions. The manner in which physicians carry themselves is sensed by those around them, but more importantly should be sensed by themselves. Employment of mindfulness strategies coupled with higher EI translates to better care by a reassured team. Although learning these tools can and may occur on the job, more opportunities should be afforded to physicians in anticipation of the challenges that lie ahead. The art of medicine encompasses the ability to adeptly navigate challenging situations with emotional equanimity. Equipping next-generation and practicing physicians with tools to enhance their EI and mindfulness by providing training while they are medical students and residents as well as throughout their professional life can only improve the field of medicine.
The authors thank Carrie Owens MSILS for editorial support.
Provenance and peer review
Not commissioned; internally peer reviewed.
This paper has been amended since it was published Online First. Owing to a scripting error, some of the publisher names in the references were replaced with ‘BMJ Publishing Group’. This only affected the full text version, not the PDF. We have since corrected these errors and the correct publishers have been inserted into the references.
Postgrad Med J. 2017;93(13):509-511. © 2017 BMJ Publishing Group
published on behalf of the Fellowship of Postgraduate Medicine