Getting a Grip on Our Emotions Scott P. Grogan, DO Faculty Development Fellow Madigan Healthcare System Joint Base Lewis- McChord, WA scott.grogan@us.army.mil "In the last decade or so, science has discovered a tremendous amount about the role emotions play in our lives. Researchers have found that even more than IQ, your emotional awareness and abilities to handle feelings will determine your success and happiness in all walks of life..." John Gottman--From Raising an Emotionally Intelligent Child There can be no knowledge without emotion. We may be aware of a truth, yet until we have felt its force, it is not ours. To the cognition of the brain must be added the experience of the soul. Arnold Bennett--British novelist and essayist, 1867 1931 Building a Case for Emotions Close your eyes and think of the last time you made a clinical decision based on a gut feeling, even if logic told you to do otherwise. Why did you do it? What was it that you felt that was so convincing to trump your logical processing? In our current training system, physicians learn to approach patients logically and with neutrality; one often hears our fellow medical professionals grumble that clinical decision-making would be better if we could just leave emotions out of it. However, it is plausible that we do not give enough credit or attention to those feelings that can help us make timely, accurate, and difficult decisions for our patients. Using concepts of emotional intelligence in medical education can assist in the development of effective communication and professionalism and may in fact go far beyond just these core competencies. We can use them to develop residents awareness and regulation of complex emotions from themselves and others. As a student or teacher, we can also use them to model and create a caring, supportive, and professional learning environment ideal for developing the next generation of outstanding military family physicians. We already know that we respond physiologically to situations long before we can respond to them cognitively. Antonio Demasio s study of the Iowa Gambling Task is widely known in the psychology community, affirming that people can sense the best deck of cards after 10 choices even though they are not cognitively aware of it until they reach closer to 40 choices. 1 Likewise, Archinard, et al. argued that facial expressions of psychiatrists during examinations of suicidal patients were more predictive of future suicide attempts than the reported perceptions of the psychiatrists themselves. 2 Their results support the fact that nonverbal cues can tell us many things that are not gained through verbal communication alone. Thus, perceived and correctly interpreted emotions will yield an enhanced understanding of the people we interact with, to include our own patients. A New Intelligence Emerges
During the 1990s, as researchers struggled to explain successes not otherwise predicted by measurements such as intelligence quotient (IQ). Mayer and Salovey then described the ability to monitor one s own and others feelings and emotions, discriminate among them, and use this information to guide one s thinking and actions. 3 Emotional intelligence (EI) thus exploded into both the psychology and business literature. With the help of psychologist Daniel Goleman, the new science spawned articles, books, examinations, seminars, international conferences, and now even Emotional Intelligence for Dummies. 4 Whereas IQ is traditionally thought of as a threshold cognitive capability, the measured level of emotional intelligence, the emotional quotient (EQ), is proposed to better predict individuals success. Indeed, in Goleman s research, successful individuals could depend on their IQ to determine success only 15-20% of the time. 5 A large portion of the remaining 80%, according to Goleman, was comprised of emotional regulation and social skills. 5 He also argued that of companies employing larger proportions of individuals with high EQs, those companies could expect an approximately 20% improvement in overall performance. 5 He uses this data to explain that no matter how smart people are or how many great ideas they might have, those individuals will never make great leaders without emotional intelligence. Since the emergence of EI, neurobiologic evidence has also shed additional light on the subject. In a study by Krueger, et al., patients with brain injuries affecting specific pathways between the amygdala, our brains emotional control center, and the prefrontal cortex, our logical processing center, have significant difficulty processing emotional data. As a result, they have a severe impairment in their ability to perceive and interpret emotional messages. This leads to a significant inability to make decisions, even on moral grounds. 6 A Model of Emotional Intelligence In the 22 years since emotional intelligence has burgeoned, multiple EI models have emerged. Goleman s ideas are probably the most commonly known and quoted, but all of the models share a similar underlying framework based, at least in part, on selfawareness, self-regulation, social awareness (empathy), and the ability to manage relationships (social skill). Self-awareness Knowing thyself has long been a mantra for philosophers and those seeking to gain self-control. In medicine, we continually seek to help our patients gain personal insight into their own diseases and emotional states to facilitate effective treatment. The concept of self-awareness should not just apply to medical conditions in our patients, however. Self-aware individuals recognize emotions that arise within themselves and feelings that others may induce in them. Likewise, a self-aware individual is likely to openly admit to failure when it occurs and will use the failure as an opportunity to grow
cognitively and emotionally. They are in touch with their strengths and weaknesses, not to mention their limitations, and can discuss them all freely and candidly. Additionally, self-aware individuals tend to transfer this skill to their organizations, becoming aware of organizational strengths, weaknesses, and limitations. Self-regulation Our emotions drive our impulses. While we cannot rid ourselves of feelings, we can control the way we react to them. Preventing a hostile emotional takeover, often referred to as the amygdala hijack, is a key component of self-regulation. Individuals with strong self-regulatory abilities can take even the most negative emotion and redirect it into something useful. They are level-headed and never lose control of their temper. They adapt quickly to unexpected changes and seem to handle them in stride. These individuals do not necessarily fit the mold of classic leaders, whose charisma and heated outbursts immortalize them. However, gifted self-regulators build trust easily amongst their subordinates and their self-control filters down to all those within their organizations. Social Awareness (Empathy) While being able to relate well to others is easy to recognize as an ability, actually utilizing it as an ability is far more challenging. Human beings have been well described in psychological research to mimic others facial expressions and moods, a concept called mirroring, which is actually the biologic basis for empathy. It is the reason that you can t help from smiling when you see a photograph of a widely grinning child. It is also the reason that, when our patients are grieving, we may grieve with them as if their pain is our own. Empathy allows us to connect with others around us, and in return, allows them to connect back to us. Empathy extends beyond our patients. As leaders of care teams, we also need to be cognizant and connected to the emotional state of our teammates. According to Goleman, empathetic leaders get into the heads of their team members, know how to deliver effective feedback, and know when to and not judiciously challenge subordinates. 5 Empathetic leaders motivate their teams though empathy in action. 5 Managing Relationships (Social skill) Just being friendly with others does not define social skill. Instead, according to Goleman, it is friendliness with a purpose; moving people in a direction you desire. 5 While socially skilled individuals do tend to be friendly, they have a wide number of acquaintances and build rapport quickly. Although, these networks are built intentionally. They realize that nothing important gets done alone 5 and, in time of need, they will have ready access to those who can help. These individuals also tend to be expert persuaders, a manifestation of the previous three skills altogether. Notably, if one has weak social skills, emotional abilities like empathy may never come through to others, negating that ability entirely. Applications in Military Graduate Medical Education
As a result of this knowledge, we will inevitably ask the questions Can we measure it? and, Can we teach it and then measure it? The answers to those questions are hotly debated in the psychological research community. There are currently numerous methods for measuring EQ, to include the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT V.2), the Emotional Competence Inventory (ECI), the Bar- On Emotional Quotient Inventory (EQ-i), the Self-Report Emotional Intelligence Test (SREIT), and the Emotional and Social Competence Inventory (ESCI), to name a few. Each test has its own focus with emphasis placed on self-assessments, peer assessments, or a combination of the two. Each has also drawn criticism in the psychological literature 7, making accurate testing and predictions of future performance more challenging. Regardless of the examination used, and whether or not training programs use testing measures at all, the concepts of emotional intelligence are being increasingly recognized as a potential marker for some of the ACGME core competencies. In 2008, Grewal and Davidson related the core competencies of professionalism and interpersonal communication to functions of emotional intelligence in residents. 8 In 2011 Shapiro followed with an argument that we largely turn a blind eye to emotions in medical education, trying to put greater emotional distance between our patients and ourselves. 9 Taylor, et al. then proposed an EI curriculum as an alternative approach to teaching professionalism to residents. 10 To date, however, few studies have been completed to address the full link between emotional intelligence and clinical and professional effectiveness of physicians; it remains an area ripe for future research. Emotional intelligence abilities are emerging as vital characteristics of becoming an effective medical professional and leader. Failing to consider the importance of these concepts limits one's ability to practice not only the science, but also the art, of medicine. When utilized and harnessed as a part of the decision making process, emotions can be powerful allies in our ability to make timely and accurate assessments of situations even before our logic sets in.
References 1. Damasio AR. Descartes Error: Emotion, Reason and the Human Brain. New York, NY: Grosset/Putnam Book; 1994. 2. Archinard M, Haynal-Reymond V, Heller M. Doctor s and patients facial expressions and suicide reattempt risk assessment. J Psychiatr Res. 2000;34(3):261-262. 3. Mayer, JD, Salovey, P. What is emotional intelligence? In P. Salovey & D. Sluyter (Eds.), Emotional development and emotional intelligence: Implications for educators (pp. 10). New York: Basic. 1997. 4. Stein, SJ. Emotional Intelligence For Dummies. Mississauga, ON:John Wiley & Sons Canada, Ltd;2009. 5. Goleman, D. What makes a leader? Harvard Business Review. 1998;76(6):93-102. 6. Krueger, F, Barbeyb, AK, McCabed, K, Strenziokb, M, Zambonie, G, Solomon, J, Raymont, V, Grafmanb J. The neural bases of key competencies of emotional intelligence. PNAS. 2009;106(52):22486 22491. 7. Conte, JM. A review and critique of emotional intelligence measures. J. Organiz. Behav. 2005;26:433 440. 8. Grewal, D, Davidson, HA. Emotional Intelligence and Graduate Medical Education. JAMA. 2008;300(10):1200-1202. 9. Shapiro, J. Does Medical Education Promote Professional Alexithymia? A Call for Attending to the Emotions of Patients and Self in Medical Training. Acad Med. 2011;86:326 332. 10. Taylor, C, Farver, C, Stoller, JK. Can emotional intelligence training serve as an alternative approach to teaching professionalism to residents? Academic Medicine, 2011;86(12):p1551-1554.