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Medicine, Health Care and Philosophy

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06.06.2022 | Scientific Contribution

Evaluating emotions in medical practice: a critical examination of ‘clinical detachment’ and emotional attunement in orthopaedic surgery

verfasst von: Helene Scott-Fordsmand

Erschienen in: Medicine, Health Care and Philosophy | Ausgabe 3/2022

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Abstract

In this article I propose to reframe debates about ideals of emotion in medicine, abandoning the current binary setup of this debate as one between ‘clinical detachment’ and empathy. Inspired by observations from my own field work and drawing on Sky Gross’ anthropological work on rituals of practice as well as Henri Lefebvre’s notion of rhythm, I propose that the normative drive of clinical practice can be better understood through the notion of attunement. In this framework individual types of emotions are not, as such, appropriate or inappropriate, but are evaluated depending on their synchronicity with the specific rhythms of the practice. To set up this proposal, I show how typical arguments about emotions in medicine—what I call emotion-entity focused frameworks—are insufficient. I then draw on ethnographic observations from two orthopaedic departments and interviews with medical practitioners to show (1) how clinical practice is driven by rhythmicity, shaped in the case of orthopaedic surgery by a clinical aim of efficient, controlled intervention, and (2) how clinicians continuously refer to this drive and the flow of rhythms when evaluating inappropriate or problematic emotion. I argue that the use of a rhythm framework rather than ideals of detachment or empathy allows for a sensitivity to the complexity and situation-dependent elements of emotional ideals in clinical practice; and I end by proposing the term ‘attuned concern’—which stresses the importance of regulation and adjustment to circumstances rather than of maintaining a constant distance/involvement—as a more fitting alternative to ‘clinical detachment’.

Ironically, one argument for detachment has been to avoid burnout, but this strategy has been challenged as there is at least a correlation between emotional disengagement and burnout (see Halpern 2001, 15n2 for more references on this).

It should be added here that although the notion is commonly ascribed to Henri Lefebvre, he developed it in close collaboration with Catherine Régulier (1957-), to whom he was also married. They have co-written on the topic, as seen in one of the texts referenced here. Lefebvre worked with the notion before he met Régulier (e.g. Lefebvre 1991, 205–7 originally published in 1974 when Régulier was still only 17)), and is credited as the sole author of the posthumous publication Éléments de rythmanalyse (Lefebvre and Lourau 1992), however the role and contributions of Régulier remain unsettled. Here I follow common practice, naming him as the theoretical source. (I thank Riki Scanlan and Stuart Elden for helpful input on this matter).

In accordance with GDPR regulations all interviewees signed a data management agreement, and no recordings were made without consent.

As my project concentrated on observing the clinicians rather than the patients, I trusted their evaluation as to when, and to what degree, to inform patients. However, in almost every encounter I greeted the patient, shaking their hand, and introducing myself by name.

Both in forms of empathy towards patients and unpleasant emotion related to ‘errors and adverse events’ (Orri et al. 2014 pp. 772–774). Some studies find that reported emotional episodes decline with experience; however, these same studies also show that emotional episodes occur throughout the career of medical practitioners (e.g. Silva and Carvalho 2016).

While the latter issue may have significant clinical consequences, I think it is important to keep the two problems separate, and thus limit the interest of this article to the first issue.

Anthropologist Rachel Prentice recounts a debate between surgeons in which they suggest a similar inclination in the term ‘compassionate objectivity’ (Prentice 2013, p. 129).

For clarity’s sake I have given most interviewees names in this article. These names are all anonymised.

Brown points to treatment of children as something that is also an emotional trigger in other historical periods (Brown 2018, p. 331). Childers and Arnold frame the same structure not in terms of only children, but in terms of unexpected death or illness (Childers and Arnold 2019, p. 31; also Aase, Nordrehaug, and Malterud 2008, p. 768).

I should note that several surgeons also recounted having no issues with operating on their actual family members, whom they love, and thus, Rose’s response is not meant as a generalisation, but as an example of moments where the intuitive concepts of ‘clinical detachment’ is invoked by practitioners.

I share this observation with Rachel Prentice, who writes, ‘Detachment does occur, but I have observed more nuance than these depictions convey’ (Prentice 2013, p. 37).

Bioethicist Jodi Halpern phrases this as, ‘Detachment is needed, physicians and nurses both assert, to concentrate and perform painful procedures.’ (Halpern 2001, p. 16).

Guidi and Traversa attach this conviction to the medical culture that came from the Flexner report which lobbied for a vast increase in natural scientific training among medical students in the US in the early twentieth century (Guidi and Traversa 2021, p. 575).

Historian Michael Brown cautions against interpreting the visual renderings of surgeons too literally (Brown 2018, p. 330). He notes that in some stages of surgical history the association between surgery and butchers was present. This link is made, however, in a context of surgeons’ wishing to emphasise the physical stamina demanded by their trade (Brown 2018, p. 331)—not the emotional.

Brown, mistakenly, I think, takes Payne’s comment on the prevailing presence of some form of dispassion throughout systematic medicine to mean a practice of lack of emotion. As the above quotation from Celsus shows, this does not seem to be Payne’s point. Rather her point is, I think, one of some form of normative stance on the regulation of emotion, much like Brown himself—even in his description of the sensitive early Victorian surgeons—stresses, using examples of a medical student who panics as an ‘example of how not to conduct oneself’ (Brown 2018, p. 342, also 335) or referring to the enlightenment ideas of Locke, Hume and Smith that one must have ‘the capacity to feel the pain of others and to moderate our actions accordingly’ (Brown 2018, p. 337, my emphasis), that is, employing specific emotions for a specific aim.

Guidi and Traversa point out that there are multiple types of empathy, arguing one is more appropriate than others, but we might also imagine that they are appropriate at different times.

They follow this point directly with the observation that surgery is nonetheless ‘charged with intense emotion’ (Orri et al. 2015, p. 7), including strong emotional bonds between patient and surgeon.

Historian Ruth Richardson speculates that the priority of the term ‘clinical detachment’ over other terms for the same intuition is linked specifically to its scientific undertone (Richardson 2000), something similar is expressed in Prentice’s ‘compassionate objectivity’ (see footnote 7).

Gross’s argument is that as a sociologist who never had clinical or medical training, she is perfectly capable of entering the surgical space with its clinical gaze at the sedated body, encountering a dear friend not as the patient she knows personally, but as brain and tumor tissue that needs to be carefully examined and dealt with (Gross 2012).

Gross is not the first to note the ritualistic aspect of surgery (see for example Katz 1981; and Hirschauer 1991).

Note, that by sensitivity here, I do not mean increased emotional sensitivity, but rather increased situational sensitivity in the framework used to discuss normativity of emotion (namely: as something relative to the rhythm, rather than a consistent level of detachedness).

There is a distinction here between emotions as had and emotions as expressed. As I am interested in normative ideals for regulation, which happens to a great extent in the interplay between the two, I will not deal further with this distinction, but align myself with sociologist Arlie R. Hochchild’s ‘interactive view’ (Hochschild 1979), that is, I have an interest in ‘how people try to feel, not […] how people try to appear to feel’ (Hochschild 1979, p. 560), or what historian William M. Reddy might be said to call a dynamic view of the relation between emotion and expression where the two work in synergy (Reddy 2001, p. xii).

Some interviewees used the term ‘natural’ when talking about these types of situations, specifically on bleeding, in several interviews; that they handled the excess of blood by reminding themselves that blood was natural. In the next part of Sarah’s scenario, vomit from the patient exits the lungs and sprays onto her, and she explains that she can see how this is disgusting, but that it didn’t feel repulsive. When I ask her if she had any hypothesis on why this was, she replied that it was natural, that if you had vomit in your lungs and someone pressed on them, it made sense that it would spray out.

By ‘friend’ she is implying a colleague (she gives as examples asking the nurse who is there with her or calling a colleague).

Orri et al. talk about how ideals of surgery revolve around the notion of the surgical procedure as the ultimate or even only cure (Orri et al. 2015, p. 10). See also Zambrano et al.: ‘Most surgeons described as an attribute of the “surgeon’s personality” their status as “people who like to fix things”’ (Zambrano et al. 2013, p. 937). Fixing something here, however, need not necessarily mean operating, but can also mean talking, referring, or explaining (Zambrano et al. 2013, p. 937), i.e. doing something.

I am not the first to use this term about clinical practice, see for example (Jensen 2016).

At this point nurses and anaesthetists had already been preparing for a while, the patient would often already be asleep (or almost asleep), and the room already set up with equipment lined up and instruments laid out, still in their protective wrappings.

In this period, I would often spend the time finding a chair and an appropriate place in the room where I could sit without disturbing, but have a proper view, and be able to hear what the surgeon said to me.

Here the notion of rhythmicity might intersect with the Weberian notion of ethics of office, that is, the expected behaviour and normativity tied to and specific to a vocation (du Gay 2008). However, my aim is not to say anything about how different rhythms come about or why they take their specific shape—questions for which looking at the formal vocational structures is most likely crucial. Instead, what I am interested in is establishing that there are rhythms, and that evaluation of emotion may depend on the way in which certain emotions fit into, or do not fit into, these rhythms. (I owe this important hook into the classic sociological literature to Cecilie Glerup).

Technically, this is not a polyrhythmia, as isorhythmia are not diverse rhythms, however, I mention it here as it is one way in which two or more rhythms can intersect (Lefebvre 2004, p. 77).

This response mirrors the response in cases where the disruption is epistemic, e.g., when patients present symptoms that the surgeon cannot make sense of, leading them either to call upon a more experienced colleague, or, if the symptoms point to a condition outside their speciality (e.g., indicating neurological issues) to refer the patient to another unit.

Bringing the parallel back to scientific practice again, Bruno Latour—drawing on the work of Isabelle Stengers—notes that ‘distance and empathy, to be useful, have to be subservient to this other touchstone [i.e. maximising occasions for inquiry]’ (Latour 2004, p. 13). That is, they are not useful per sec but in relation to the optimisation of scientific practice.

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Titel: Evaluating emotions in medical practice: a critical examination of ‘clinical detachment’ and emotional attunement in orthopaedic surgery
verfasst von: Helene Scott-Fordsmand
Publikationsdatum: 06.06.2022
Verlag: Springer Netherlands
Erschienen in: Medicine, Health Care and Philosophy / Ausgabe 3/2022
Print ISSN: 1386-7423
Elektronische ISSN: 1572-8633
DOI: https://doi.org/10.1007/s11019-022-10088-x

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