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A Ring of Truth?

I have my great-grandmother’s engagement ring in my jewelry box. The bridegroom was of modest means and the ring was very inexpensive – made of cheap materials with cheap stones – but it meant the world to the young couple. Over the generations it became worn, losing several itty bitty stones. For a time when I was just out of college, I tried to have it repaired and resized so that I could wear it since I have always loved family things even though it had no real monetary value. After all, it is Great-grandma’s engagement ring.

No jewelry repair shop would touch it, saying it would cost more to repair than it was worth and that their repair techniques would probably destroy it given the materials and construction. They suggested taking it to a jewelry designer, but none of them would touch it either. I tried to understand their logic. The actual material value of that ring is negligible. What I wanted restored to its prior level was emotional, a link to the past, to people I’d never met but who are a part of me. The jewelry repair person’s dispassionate analysis was that this ring can’t be fixed. As a sometimes-hyperemotional great-granddaughter, my passionate analysis wanted to restore something that jewelry repair technology couldn’t fix.

Passionate and Dispassionate Analyses

Is it possible to be both passionate and dispassionate at the same time? Absolutely. Dispassionate (“not influenced by strong emotion, and so able to be rational and impartial”) describes scientific knowledge. It is not the opposite of Passionate (“showing strong feelings or a strong belief”) (Oxford Dictionary). It all depends upon what we are passionate about. Many people equate “passion” with “enthusiasm” and ideally we are passionate about our work while still being objective. If we equate “passionate” with emotionality, then objectivity can suffer in the face of emotion. Clinicians must be both caring and competent. They must be able to communicate with patients in a way that objectively conveys science while still providing empathetic emotional support (Rosenberg & Edt, 1977). Empathy cannot cloud the objective assessment. Objectivity need not obscure the caring.

We care for and about our patients but must be careful not to let the enthusiasm that comes from caring keep us from the necessary emotional detachment to remain clinically objective. A scientist (clinician) who is passionate about his or her work is enthusiastic and driven… without being biased (Martin, 2013). The passionate scientist (clinician) perseveres using known facts and established scientific (clinical) methods. The greater the passion, the more work the scientist (clinician) does. But facts and data do not change as the scientist’s (clinician’s) passion grows.

“But I’m just a caring person.”

Separating passion from dispassionate analysis can be difficult. Consider the physician. The language of medical knowledge comes with objectivity and scientific competence, while empathy and relationships comprise the “caring” piece (Macleod, 2015). The physician describes to the patient and the family the outcomes of a diagnostic process, presents a prognostic statement, and outlines treatment possibilities. When the disease is a type or extent for which treatment cannot lead to cure, medical intervention may offer no more than comfort. Treatment explanations should reflect those expectations, but these conversations can be difficult for everyone. In some cases, overly aggressive care is provided not for clinical reasons but due to guilt, grief, fear of legal repercussions, and concerns about family reactions (Jox, Schaider, Marckmann, & Borasio, 2012). Jox et al. (2012) describe physician comments lamenting such care (“We have become so conditioned that we have to do everything.” “We could then honestly say we had done everything we could.”) (p. 542). Such care likely prolonged a very difficult situation for a family that was already suffering.

Empathy is important in clinical interactions and for some this side of communication is easier. In medical education, programs separately teach scientific knowledge and empathetic communication. In speech pathology preparation, such didactic separation is less likely to exist. Some speech language pathologists might be more comfortable providing emotional support than describing and discussing difficult clinical situations where the prognosis is poor. For many physicians, the supportive communication piece may be more difficult; empathy is a component of medical training which is taught, practiced, rated, evaluated and scored (Nunes, Williams, Sa, & Stevenson, 2011).

Thinking about the therapeutic toolbox

It’s not just in end of life issues where passionately dispassionate practice is necessary. We must objectively evaluate all we do and not let a fervent wish to help cloud that objectivity. There are assessment procedures that clinicians describe that are not supported in the literature (e.g. pulse oximetry, cervical auscultation). Consider the inappropriate use of non-speech oral motor exercises, irrational fear of aspiration without understanding the complex relationship between aspiration, body systems, oral bacteria and disease, and general use of therapeutic programs that “someone says work.” Sometimes clinical methods, materials and programs become widely used before any evidence supporting them has been obtained (Lof, 2011). Some have been used for years. All actions have consequences, and we are responsible for all consequences of our interventions, even the unintended ones. It’s our job to understand our interventions well enough to know the consequences. In discussion lists and social media, when clinicians are reminded that such-and-such measure is not supported in the literature, the response is often that it is just another tool in their clinical toolbox.

Photo credit: zzpza via Foter.com / CC BY
Photo credit: zzpza via Foter.com / CC BY

How do we choose the tools in our toolbox? Are they all reasonable? A jewelry repair person doesn’t have duct tape or a sledgehammer in his toolbox. Tools need to have evidence behind them, or they are simply trappings. Implementing procedures with no supportive evidence behind them is a disservice to patients. I remember pleading with the jeweler that he just try anything – anything at all – to fix my grandmother’s ring, and that I was willing to take the risk that the ring would be damaged. The refusal was based on their expertise and professional judgment. There was no reasonable expectation of success, given what they knew about the ring coupled with the known science and art of jewelry repair. It did not matter how much I wanted the ring to be repaired.

It does not matter how much we want something to work if there is no compelling evidence that it does. Pulse oximetry cannot identify aspiration no matter how much we might want it to, and there is no correlation between the diagnostic powers of pulse oximetry and the difficulty in obtaining instrumental assessments (there MIGHT be a correlation between the USE of pulse oximetry and difficulty in obtaining instrumental assessments). Cervical auscultation has similar limitations at present. The focus needs to be on obtaining those instrumental assessments, not pursing routes that don’t address the real problem.

Recent social media posts sometimes describe therapeutic processes and modalities offered for CEUs. Clinicians using these methods should submit to peer reviewed journals so it can be objectively determined whether or not they work. We must be able to differentiate clinical processes which have a scientific foundations from pseudoscience (Lof, 2011). We must not let our passion for promoting recovery affect our ability to critically evaluate the therapeutic programs we implement. We must carefully and objectively choose each tool that goes in the toolbox.

The toolbox should hold effective and valid items. Duct tape may appear to fix many things, but it never fixes them well. Neither does a sledge hammer.

“All I know is that I just care about my patients.”

Caring is separate from competence. Objectivity about our patient’s status, realistic prognostic statements, and scientifically supported recommendations, with appropriate emotional support, are markers of effective clinicians. We do not “care more” if we try every possible treatment we can think of with no clinical foundation. We are not “more caring” if we deny the reality of an objective assessment.

It may not matter how much we want our patients to be restored to their prior level. Aimless application of treatment modalities that have no reasonable expectation of success is not fair to patients. It is a waste of their time and money, and is a violation of the Code of Ethics (American Speech-Language-Hearing Association, 2010). It is our responsibility to apply these principles and present honest options to patients with dispassionate analysis of reasonable expectation of benefit. The jeweler did just this when I wanted to try “anything.”

A passionate (emotional) expectation for recovery may not be realistic, and if only restoration of function defines clinical success for us, then we have been passionate (emotional) without being dispassionate (objective). Arguably, it’s very possible that our emotional need for our patient to “get better” may not even be consistent with the patient’s own wish for his own care – he may have accepted a medical situation and be at peace with his situation. Many of us joined this profession wanting to help people recover/rehabilitate/get better, and we do so. But as our profession’s scientific foundations become more detailed, we will continually be in an even better position to understand the potential and the limitations of what we can do to restore function. It is as important to know what we cannot fix as it is to know what we can. It is important to remember that “fixing” is not the only thing we do for our patients. We must remember that as the science advances and we learn more, our practice patterns must also change. It does not take long to become “old school.”

It has been at least 25 years since my trek to the jeweler to get Great-grandma’s ring repaired. I just looked at it, and yikes, it really is in pretty bad shape. What was I thinking?? I was thinking about the passion for the family and not the dispassionate reality of jewelry repair. I can now understand why a jeweler would want nothing to do with trying to repair it. But I will always have a passion for family things.

And I’ll continue to work on being passionately dispassionate, always learning, to provide my patients the best care I can.

 

References

  1. American Speech-Language-Hearing Association. (2010). Code of Ethics.
  2. Jox, R. J., Schaider, A., Marckmann, G., & Borasio, G. D. (2012). Medical futility at the end of life : the perspectives of intensive care and palliative care clinicians. Journal of Medical Ethics38(540-545). http://doi.org/10.1136/medethics-2011-100479
  3. Lof, G. L. (2011). Science-based practice and the speech-language pathologist *, 13(May 2010), 189–196. http://doi.org/10.3109/17549507.2011.528801
  4. Macleod, A. (2015). Caring , competence and professional identities in medical education education, (July). http://doi.org/10.1007/s10459-010-9269-9
  5. Martin, W. J. (2013). Science is dispassionate, we are told. Annals of the American Thoracic Society, 10(4).
  6. Nunes, P., Williams, S., Sa, B., & Stevenson, K. (2011). A study of empathy decline in students from five health disciplines during their first year of training. International Journal of Medical Education, 12–17. http://doi.org/10.5116/ijme.4d47.ddb0
  7. Rosenberg, C., & Edt, A. M. (1977). The Therapeutic Revolution : Medicine , Meaning and Social Change in NineteenthCentury America. Perspectives in Biology and Medicine, 20(4), 485–506.

3 COMMENTS

  1. This is a wonderful, thought-provoking article. Years ago my clinical professor taught us about “clinical distance” as a set of key skills. Clinical distance was remaining objective when faced with an emotionally charged circumstance, remaining compassionate without getting too involved personally, and prevention of the depletion of self over the years (now known as compassion- and caregiver-fatigue). Your article carefully and sensitively expounds on these concepts. Patients, clients, families, clinicians and colleagues all benefit when mentors, teachers and programs foster awareness of the importance of development of these critical skills. On a personal note, my late grandmother’s favorite “pearl and gold” costume brooch was treated by a jeweler much the same as your great-grandmother’s ring. His words “it’s not worth repairing” did not deter me. I got him to repair it, but his words stay with me to this day.

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