Letters to the Editor

To the Editor:—We commend Dr. Shanafelt et al.¹ on their recent study noting an association between higher mental well-being and residents' capacity for empathy, comprising the “cognitive” capacity for insight into others' experiences and the “emotive” capacity to respond to these experiences. Although the use of the SF-8 to measure well-being only presents a limited assessment of aspects of physical and mental health, their findings support the need for further empiric work about the nature and promotion of resident well-being. In this study sample, female residents had higher emotive and cognitive empathy scores compared with men, but a lower proportion of female residents possessed “high mental well-being.” This intriguing finding raises further questions about the interactions between empathy and well-being and the implications for future research.

A recent review described clinical empathy toward patients as emotional labor.² Physicians may use 2 different modes of acting to express empathy: (1) “surface acting”—displaying behaviors unmatched by underlying emotional content and (2) “deep acting”—modifying their underlying emotions to create congruency with these behaviors. Larson and Yao argue that recurrent surface acting by physicians may actually lead to cynicism and burnout, although there is a lack of empiric studies to support this belief. If this conjecture is true, residents who possess a high capacity for empathy may have decreased mental well-being over time because of this persistent dissonance between their underlying emotional state and their performance as empathic physicians.

Another concern is that too much empathy for patients could lead physicians to sacrifice aspects of their own well-being. Some physicians with high empathy may be unable to set the necessary boundaries to protect their own well-being. Huggard³ describes the phenomenon of “compassion fatigue,” whereby physicians who engage empathically with their patients develop burnout because of secondary traumatic stress. Perhaps in Dr. Shanafelt's study, the wellness promotion practices of residents with high mental well-being enable them to demonstrate empathic concern while still maintaining their own well-being and averting burnout.

Striking this balance between empathy and self-care may be a critical skill for residents to master and may help to ensure well-being throughout their careers. Further explorations of gender differences in clinical empathy may help elucidate how the risk of burnout or compassion fatigue may differ between female and male physicians. We appreciated the contribution of Dr. Shanafelt and his colleagues to our understanding of these important connections.