One of my favorite bumper stickers reads, "Who Cares About Apathy?" I suspect a fair number of physicians have held up their hands in exasperation and said the same about empathy. Kelly Edwards's article, "Critiquing Empathy," in the December 2000 issue of Second Opinion, reflects some of the frustration with the call for more empathetic physicians. She is "leery of relying on empathy in therapeutic relationships" and in the end calls for a "new metaphor, stance, and practice."¹

In his editorial remarks, Martin Marty casually introduces the idea of "equipoise." This Aristotelian concept, according to Marty, is able to "do considerable service during diagnosis or for description" of situations of importance in the therapeutic relationship.² Consistent with the intent of Second Opinion, Marty opens the door for readers to offer a Second Opinion; I wish to offer just that.

To answer Edwards's call, we do not need to look far for an alternative to empathy, and it would be odd to call this alternative new. Perhaps the word "reinterpreted" would be more appropriate. I am thinking of William Osler's much maligned doctrine of aequanimitas, or what we would today call equanimity. In the history of western medical education there are precious few others in Osler's class. Although he died in 1919, his influence is still widely recognized today. Mark Siegler notes:

Siegler quotes Osler on the importance of bedside education: "[the] student begins with the patient, continues with the patient, and ends his study with the patient."⁴

Although the interpreters of Osler's concept of equanimity have used it to advance an apparent need for detachment between physician and patient, I would offer a reinterpretation that could serve as the much needed "new" practice. Equanimity calls for an initial and essential connection between physician and patient, but recognizes and maintains an equally essential distinction between self and other. But first, let me focus on the problems with empathy and with detachment.

THE PROBLEM WITH EMPATHY
Kelly Edwards notes a number of problems with empathy, the most significant of which is the loss of self in the other. She calls this "identification or 'I am you,'" and it seems to me she is quite right.⁵ Theorists may argue that Edwards and I fail to truly understand how empathy works. But if this is the case for those of us who study such concepts at length, how much more difficult it is to teach empathy to medical students whose schedules and minds are filled with far more pressing issues. Too intimate a connection between physician and patient is more disabling than not, and will result in less advantageous healing for the patient.

William Osler recognized this difficulty and offered the language of detachment in response. In his famous, or perhaps infamous, lecture entitled Aequanimitas, he urged his physician audience to cultivate obtuseness, insensibility, and callousness. Equanimity was his idea of the mental equivalent of imperturbability, which is a bodily virtue. The combination of these two virtues was intended to provide a "coolness and presence of mind under all circumstances." Cultivation of these qualities would result in a clarity and calmness of judgment for physicians. Osler believed that the patient would benefit more from the therapeutic relationship when the physician was so enabled. These qualities were not simply an advantage to physicians; they were a "positive necessity." Physicians of this sort were more appreciated by their patients and were, indeed, a "comfort to all who come in contact."⁶

How times have changed. Either patients were very different in those days or this brief portrayal of Osler's aequanimitas is unfairly skewed. Perhaps both. One can easily imagine, however, why Osler interpreters have felt him to be the father of detachment.

THE PROBLEM WITH DETACHMENT
Upon closer reading, it is clear that Osler was aware of the problems associated with his notions of the ideal physician. He realized that equanimity was likely to be misunderstood and that the "accusation of hardness, so often brought against the profession, has here its foundations." But it was not simply the misperception of patients that Osler addressed. He recognized the problems with detachment and offered the language of connection in response. He recognized the impossibility of such a thorough "escape from the cares and anxieties" of the physician's connection with patients. His notion of equanimity was not a cadre of emotionless physicians who had no empathic connection with patients. Rather, it was an equanimity that would allow physicians to "bear with composure" the misfortunes and failures attendant to the therapeutic relationship.⁷ He envied nurses the continual close connection they shared with patients. Osler insisted that "constant contact with disease" is that to which "any physician of twenty years standing" would point as the source of their clinical proficiency.⁸ And despite the difficulties of being in connection with people who suffer illness, Osler urged an "infinite pity" toward the suffering, coupled with "tenderness and consideration to the weak . . . a broad charity to all."⁹

In a spontaneous address to a group of medical students, Osler clarified the nature of his concern toward this therapeutic relationship-the essence, I would argue, of his notion of equanimity:

The problem with detachment, or as many paradoxically put it, "concerned detachment," is that its essential starting point is separation. Rather than communicating care and acceptance to the patient, the physician who begins with detachment communicates impatience, nonchalance, or perhaps even the contempt Osler warned against.

If the problem with empathy is over identification with the other, then the problem with detachment is failure to identify at all with the other. Clearly, some middle ground between the two should be our aim for establishing a new practice.

REINTERPRETING AN OLD PRACTICE
Reinterpreting and reintroducing William Osler's doctrine of equanimity holds great promise for educating young physicians in the finer points of therapeutic relationships. By definition, equanimity calls for a balance between two extremes-an emotional balance that is particularly helpful when one is facing some quandary or stress. In the Aequanimitas address Osler refers to it as a "mental equilibrium" that was to characterize the thinking of practitioners. The virtue equanimity describes a balance inclusive of emotional engagement with the suffering patient, not an imbalanced disengagement that provides a false sense of self-protection for the physician.

As is often the case with virtues that call for a balance between extremes, this mean is difficult to achieve. It must begin with an effort to connect with the patient rather than assert professional distance.

Jodi Halpern offers a modified view of empathy that emphasizes the initial connectedness essential to the therapeutic relationship. The physician is called to "resonate" with the patient emotionally. By emotional resonance, she means "the spontaneous experience of emotion stimulated by another person's like emotion." This emotional connection does not blend the two parties in some ethereal oneness of encounter. Rather, "resonance emotions are like stage lighting that sets the mood for a play." As the play advances from scene to scene the characters must maintain necessary distinctions to remain uniquely identifiable.¹¹

Physician Rita Charon describes the kind of distinction that must remain in the physician-patient relationship:

Recognition of the necessary distance between physician and patient calls for a rejection of the kind of empathy Carl Rogers defines and Edwards is leery of. Equanimity allows for this distance but halts the swing of the pendulum before full resonance with the patient's emotional sensitivities occurs. Charon urges physicians to allow the suffering of patients to "come close" through what she calls "transformative compassion":

This "isolation and strangerliness" makes for often awkward and difficult moments in the physician-patient encounter, particularly at the outset. Emotional connection with patients who are feeling this way can make a crucial difference in the development of the healing relationship. Alisa Carse argues against those who think that the distance necessary for physicians to do what has to be done is "incompatible with the emphasis on compassion and sympathy." She holds that there is nothing intrinsic to this type of care that would exclude "appropriate detachment, or equanimity." Carse goes on to posit a central concern for the therapeutic relationship, which is to ask "how we can widen and expand our emotional knowledge and imaginative power and encourage in ourselves and others the ability to enter into the feelings and perspectives of others without taking possession of others' suffering, or exploiting others' vulnerability to serve our own psychological or material ends."¹⁴

Equanimity on the part of the physician allows for the sort of initial connection that can incorporate the feelings and perspectives of patients. Rather than concerned detachment that presents merely the facade of care for patients, physicians would do well to practice the virtue of equanimity. This kind of relationship seems to be that which is sought by those who advocate empathy among practitioners.

Edwards concludes her essay by sharing her hope that within the "relational space" of the therapeutic encounter, medical student education can be advanced without the troublesome concept of empathy. Indeed, in medical education the competent professional should "practice skills and behaviors that can be taught, modeled, and cultivated to become habits."¹⁵ Perhaps equanimity can be one of the virtues so established.

Kelly A. Edwards responds:

The intention of my recent essay, "Critiquing Empathy,"¹ was to illustrate the need for a nuanced view of professional virtue that would provide meaningful guidance to medical training and practice. I began by identifying five critiques of empathy, a virtue that, while commonly referred to in medical education, is little understood. Mark Carr responds in this issue of Second Opinion with a virtue for us to consider. He redirects our attention to William Osler's concept of aequinimitas.

Dr. Carr's alternative to empathy responds to one of my criticisms of the practice of using empathy as an ideal virtue. A frequent critique of empathy as an ideal is that it could lead to over-involvement with the patient or a clouding of the physician's judgment. Carr recognizes this shortcoming and points us to Osler's aequinimitas as a way to maintain balance between distance and attachment. This famous stance of "detached concern" has been one way that physicians have been able to escape this one pitfall of empathy and pursue their professional responsibility. I find this a worthy direction, but feel compelled to offer two points of caution.

My first point has to do with the challenge of achieving balance between distance and attachment. Carr's description of equanimity finds middle ground between empathy and detachment. However as Carr admits, many have interpreted Osler's call to "callousness and coolness" as detachment and a retreat to objectivity. I agree that the theorists among us can return to this concept and find the balance point between empathy and detachment, regaining the connection to the patient through appropriate distancing. However, I share the concern of others who have seen this ideal become skewed in training and practice.² When teaching detached concern, educators all too often emphasize experiences that create detachment without including an emphasis on concern. Like empathy, equanimity is open for misinterpretation. Perhaps the lesson for us is that as educators and theorists, we should promote dialogue and foster understanding around these virtues, rather than presuming that what is clear to us is equally clear to our students. As with other complex skills, virtues evolve best through reflective practice.³

I can appreciate the importance of developing the skills of balance and attenuation. Keeping this focus helps develop self-reflection skills in the physician and allows attention to be paid to the physician's self in addition to the patient's. However, over-identification is only one of the dangers of empathy. Other critiques I discussed include: trivialization, devaluation, missing emotional attunement, and domination. I remain concerned about patient encounters where negative emotions are present, or where no emotional resonance exists. Or the encounter where the physician presumes to know the patient's concerns, but in fact has missed them completely. These critiques remain relevant here. Exhaustion, time pressures, and prejudice can prove difficult customers for a professional ideal based on emotional attunement. A physician still has a responsibility in these cases. Where does the motivation for this responsibility come from, and how does the physician find guidance for his or her actions? I reiterate my call for shifting to virtues that attend to the dialogic relationship, and pedagogies that cultivate responsiveness and self-awareness.

When one looks into the literature on professionalism, there is an array of metaphors and virtues from which to choose. Martin Marty reminds us of Aristotle's equipoise, the balancing required when working with conflicting demands.⁴ John Coulehan argues persuasively that we may need to shift out of the distancing metaphor altogether.⁵ The language of "distance" and "involvement" sets up a false dichotomy in which the clinician must negotiate a balancing point. Coulehan offers up "tenderness and steadiness" as a way of communicating the idea of complexity and competing demands, while stepping outside of the bounds of the usual discourse. Similarly, William Branch proposes an ethics of caring, which pairs receptivity-an empathy-like emotion-with responsibility.⁶ Responsibility for Branch is based on the old-fashioned, but still relevant, ideal of duty. As stated in the first version of the American Medical Association's Code of Ethics, duty means that "the physician should be ever ready to obey the calls of the sick."⁷ Or to take it a step further, one might consider responsibility in light of the principle of beneficence: "be of benefit and do no harm." How one can accomplish this, or what skills one may need to do so, remains an open question. Nevertheless, the pairing of receptivity with responsibility, or tenderness with steadiness, strikes me as one approach toward articulating the multifaceted notion of professionalism.

VIRTUES TO GUIDE THE MEDICAL PROFESSION
The dialogue Dr. Carr initiates suggests a promising direction. Rather than searching for a Holy Grail of medical virtues, one or more that would definitively describe the professional responsibility of a physician, perhaps we should be engaged in critical dialogues about the possibilities. There is a panoply of virtues, and a rich vocabulary, which our philosophical and medical ancestors have bequeathed us. Carr's approach is a good one. Revisiting and re-imagining these older virtues may well help us find "new" metaphors, stances, or practices to guide medicine. Who knows? Medical professionalism may thrive with a version of the ideal that is dynamic, fluid, multivoiced, and ambiguous. Perhaps instead of viewing ambiguity as a shortcoming, we can use the complexity to create room for the dialogue.⁸

NOTES (Carr)
1. Kelly A. Edwards, "Critiquing Empathy," Second Opinion, no. 4 (2000): 35-47.

NOTES (Edwards)
1. Kelly A. Edwards, "Critiquing Empathy: Insights for Professional Education," Second Opinion, no. 4 (2000): 35-47.