Empathy has been shown to improve patient care and physician well-being. However, the emotional labor involved in expressing empathy might interfere with experiencing calm, equally important to clinicians' well-being. This article offers examples of how clinical environments can bolster both empathy and calm and suggests that empathy can be expressed socially, not just individually, to build solidarity and make space for calm.
Emotional engagements—such as empathy—have been shown to improve patient care,1- 6 physician fulfillment,3,7- 9 and the health of the entire care team,2,3,6,8,10,11 and therefore they should be encouraged in clinical practice. However, these benefits must be measured against the obstacles to empathy in the structure of clinical training and practice.7,12,13Quiz Ref IDIn a profession inundated with expectations, adding more should not be taken lightly. Specifically, the emotional labor involved in empathy could hinder emotional stillness, or calm, which is the state of not being pulled by any strong emotions. The ability to experience this restorative state is equally as important to physician well-being and patient care as empathetic engagement.14 But how can the demand for empathy be balanced with the need for calm?
One possible answer is for physicians to “extend” some of their emotions to the local environment. While there are variations on this relatively new theory—often referred to as extended mind theory—it generally hypothesizes that mental activities and contents could extend beyond the brain.15- 17 There are 3 ways philosophers have argued that emotions could be extended17,18: (1) by parity (or functional similarity between internal processes and external resources), (2) by integration of internal processes and external resources, and (3) by social approaches. Here, I apply recent research on extended emotions and recommend 3 possible changes that can be made to clinical practice to simultaneously bolster both empathy and calm: (1) the use of physical prompts, such as notes and posters (parity), (2) the integration of music, and (3) social extension of emotions across a clinical team.
Parity approaches to extended emotion focus on how features of the environment function like cognitive processes.15,17 Consider the way that someone with Alzheimer's may use a notebook as a reliable tool to remember important information when their memory might fail them.15 If these patients need to remember something, like directions, they record it and reference it when needed. Clark and Chalmers argue that the notebook functions like memory and thus deserves some epistemic credit for the remembering.15 In clinical practice, parity of memory and physical structures would be akin to the use of checklists and databases to off-load some of the labor of memorizing patient information. This approach, however, would have to work differently for emotions like empathy.
Quiz Ref IDWhen defined as an understanding of others' mental states, empathy is an excellent candidate for extension. Empathy—both basic and narrative—can be functionally bolstered by the environment. In its most simplistic form, empathy is a curiosity about the other's experiences.3,19 In the medical setting, basic empathy can be extended in the local environment with reminders for clinicians to ask how patients are experiencing their illnesses, thereby encouraging clinicians' curiosity even when it is lacking or inconvenient. Such reminders could include notes on exam sheets or computer prompts.
In its more complex narrative form, empathy occurs when physicians indulge the curiosity of basic empathy and co-construct narratives with patients to best understand their situation.3,20,21 Narrative empathy does increase emotional labor, but it need not be entirely reliant on the physician. Quiz Ref IDPatients can be primed to share their stories in a variety of ways, including handouts at check-in, videos in the waiting room, or posters in the exam room. In the same way that there is space for posters that say, “Ask your doctor about this medication” or “Tell your doctor about these symptoms,” there could be patient guides for best informing physicians about one's experience of illness. For instance, a poster could say, “Don't forget to tell your doctor about your experiences leading up to your symptoms” or “Doctors also want to know about your emotional experiences; tell them how you feel.” Such posters would help patients co-construct their narratives with their physicians for a more accurate understanding of their symptoms or condition. In this way, physical structures that provide prompts can be used to alleviate some of the physician's active focus on empathy in order to make space for calm.
The second approach to extended mind—integration—argues that some of our environmental resources become so integrated with us that it would be wrong to label them as separate systems.17,22 Remove that resource, and those experiences or abilities would be either impossible or significantly hindered. For example, resources that are “tools for feeling” help us cultivate specific emotions by providing feedback, which makes them more integrative than the functional fillers of parity extension.22
One notable way that we integrate with the environment to extend our emotions is through music,22- 24 but we can also commonly do so with keepsakes and even other people.23,25 Krueger argues that “the listener offloads some of the regulatory and emotional work onto the music—and the music thus becomes part of the extended vehicle needed to bring about certain emotions.”22Quiz Ref IDMusic and listener are an integrated system when it comes to emotional regulation. Music even “mobilizes participants to act in contextually appropriate ways,”22 such as somber music for grieving or upbeat music for celebrating. Relying on music for emotional regulation helps us enter into desired emotional states and better recognize our current emotions. Given the importance of music to emotional life, it is not only odd but also damaging that most clinical settings are sterilely silent.
One way to bolster calm for physicians, then, would be to integrate music into the clinical environment. People already use music in spaces and at times set aside for calm, such as during meditation or a massage. However, integrating music into medicine would require some trial and error to determine what works best, since clinical practice requires periods of focus and strong, guiding emotions. As one option, calming music could be played at a low volume in all locations—from waiting rooms to exam rooms—with the volume periodically increasing and decreasing to encourage moments of calm. Alternatively, the music could be played at a low volume in most areas but be noticeably louder in break areas, indicating that those are areas for restorative calm.
Social extension is the most controversial approach to extending emotion, but it may be the most adaptive to clinical practice. The trick is rethinking how to attribute emotions. Consider Scheler's explanation of grieving parents.26 Scheler argues that the grief experienced by the 2 parents cannot be properly explained as 2 different, but simultaneously experienced, emotions. Rather, it should be understood as their shared grief felt for the loss of their child.27 The emotion is spread out between them. Other emotions can also fit this mold, belonging exclusively to neither one nor the other but rather belonging equally to multiple subjects.18 Social extension of emotion can include large-scale examples like mass panic or small-scale examples like romantic love.23
In clinical practice, social extension of emotion involves rethinking the recommendation that physicians be more empathetic. Rather than interpreting this as the need for each individual physician to be more empathetic, it should be interpreted as the need for the clinical team to be more collaboratively empathetic. Socially extending narrative and basic empathy would, in turn, bring greater emotional solidarity to the care team and serve to make space for calm.
Narrative empathy.Quiz Ref IDThe construction and communication of narratives should be shared among team members. Different members of the clinical team experience the patient's story differently. Taken alone, these narratives are only partial understandings. Taken together, these partial understandings deepen empathy with the patient by extending empathy across multiple clinical professionals. Co-constructing narratives with patients likewise gives patients more opportunities to explain their perspectives and feel heard, which can itself be healing.
Basic empathy. The extension of empathy as a feeling of curiosity would be similar to grief in that it would be felt among multiple people. It would be the collective, dynamic feeling of curiosity and openness towards patients. Members of a clinical team could both (1) be open to the patient's experiences at different times and (2) help regulate group empathy by reminding members to be empathetic—whether through example or commentary.
Empathy should be encouraged among the members of a team, so that they can be better attuned to their patients' emotional needs. Rather than empathy being delegated to one empathetic nurse who carries the bulk of emotional labor, empathy should be socially extended to all the members of the clinical team. Other emotions, such as sympathy or even calm, could also be socially extended.
These are only a few representative examples of how emotions could be extended in clinical practice. Despite their simplicity, each of these means could be significant in lightening physician responsibilities and for improving patient care and physician well-being. Conceiving of some emotions as capable of being extended in different ways reduces the demands on any single clinical professional, better enabling calm, if only by making space for it. More efficient use of space via physical prompts can help physicians empathize with their patients. The integration of music can help bolster the experience of calm. Finally, accepting the social extension of empathy as a shared experience and responsibility would lessen the emotional labor of any single clinical professional.
One purpose of this article was to facilitate thinking about clinical environments as essential parts of ethical behavior and experiencing calm. Future research should expand on initial applications of extended emotions to examine practical implications of both the applications suggested herein and the emotions they extend. What are limitations of narrative empathy? How should we ensure consistency when narratives are constructed by a team? When is music calming? Through questions such as these, extended emotions reveal new areas of research and ways to improve clinical environments.
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The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more
AMA Journal of Ethics
AMA J Ethics. 2022;24(12):E1135-1140.
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Credit Designation Statement: The American Medical Association designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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Carter Hardy, PhD is an assistant professor in the Department of Philosophy at Worcester State University in Massachusetts. He earned a PhD in philosophy from the University of South Florida with a focus on biomedical ethics and moral emotions. He has published papers on the role that empathy, sympathy, and humor should play in medical practice and is currently examining the role that other moral emotions should play in medicine, as well as how they could best be taught and implemented.
Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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