Perhaps in Dr. Shanafelt’s study, the wellness promotion prac-
tices 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 en-
sure 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 under-
standing of these important connections.—Neda Ratan-
awongsa, MD, Scott M. Wright, MD, Rachel B. Levine, MD,
MPH, Johns Hopkins School of Medicine, Baltimore, MD.
1. Shanafelt TD, West C, Zhao X, et al. Relationship between increased
personal well-being and enhanced empathy among internal medicine res-
idents. J Gen Intern Med. 2005;20:559–64.
2. Larson EB, Yao X. Clinical empathy as emotional labor in the patient-
physician relationship. JAMA. 2005;293:1100–6.
3. Huggard P. Compassion fatigue: how much can I give? Med Educ. 2003;
In Reply:—We thank Drs. Ratanawongsa and colleagues
for their insightful comments. Larson and Yao’s
‘‘surface acting’’ and ‘‘deep acting’’ is a useful method to con-
ceptualize the ways physicians express empathy. In addition
to potential effects on the patient’s experience, the way physi-
cians respond to patients can positively (enhanced meaning/
personal fulfillment) or negatively (burnout, compassion fa-
tigue) impact physician outcomes.
Although we believe surface acting is appropriate in many
situations, the motivation behind use of this technique is im-
portant. We agree with Larson and Yao’s
assertion that sur-
face acting motivated by a ‘‘value guided commitment to care’’
can contribute to both patient and physician satisfaction. In
contrast, repetitive use of surface acting simply to avoid deal-
ing with patients’ emotional concerns is likely to contribute to
Deep acting has the potential to create an even greater
connection between physicians and patients as well as
enhance physicians’ sense of meaning in their work. This ap-
proach, however, involves physicians altering their own emo-
tional state to identify with the patient’s experience and has
the potential to create reactive emotions (anger, distress, con-
cern, and grief) for the physician. Physicians who are able to
recognize and process such personal reactions are better able
to express empathy without experiencing ‘‘compassion fa-
tigue.’’ We believe training medical students and residents to
calibrate their use of surface and deep acting and identify
personal reactions in each patient encounter is an important
step in developing physicians who are both empathetic and
The energy physicians can devote to emotional labor is
ultimately a limited resource. We hypothesize that attention to
personal well-being through mindful practice and nurturing of
personal interests and relationships allows physicians to re-
new the energy they have to devote to this work.
holds that empathy and well-being have reciprocal feedback
loops. The complexity of these interactions highlights the need
for additional studies on the relationship between well-being
and empathy and research that provides insight into how phy-
sician well-being can be promoted. We hope that support for
such studies will grow in the coming years.—Tait Shanafelt,
MD, Colin West, MD, PhD, Joseph Kolars, MD, and Thomas
Habermann, MD, Mayo Clinic College of Medicine, Rochester,
1. Larson E, Yao X. Clinical empathy as emotional labor in the patient-phy-
sician relationship. JAMA. 2005;293:1100–6.
2. Epstein R. Mindful practice. JAMA. 1999;282:833–9.
3. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C.
Calibrating the physician. Personal awareness and effective patient care.
Working group on promoting physician personal awareness, American
academy of physician and patient. JAMA. 1997;278:502–9.
4. Novack D, Epstein R, Paulsen R. Toward creating physician-healers:
fostering medical students’ self-awareness, personal growth, and well-be-
ing. Acad Med. 1999;74:516–20.
5. Shanfelt T, Sloan J, Habermann T. The well-being of physicians. Am
J Med. 2003;114:513–7.
To the Editor:—Franks et al.’s
article entitled ‘‘Racial dis-
parities in the content of primary care office visits’’ observed
that African-American (AA) patients are less likely to receive
preventive care during office visits to primary care. The au-
thors present an interesting study and do a good job enumer-
ating and addressing the limitations of their dataset and
analyses. Still, we feel 2 points merit further discussion:
1. That AA receive more of some preventive services and less of
others does not make intuitive sense. If ethnicity were a di-
rect determinant of preventive services, then the relationship
should be independent of the type of service in question. In
absence of a consistent relationship between ethnicity and
the type of services offered, we must consider the existence
of an unadjusted confounder. Attempts to explain this phe-
nomenon should consider not only provider characteristics,
but also those of the patient and site of care as well.
2. That the disparities observed for one time period do not per-
sist into the following one suggests that, regardless of the
mechanism for the disparities, they are waning over time.
Rather than focus on the causal mechanism for disparities,
we should celebrate that the only remaining significant dis-
parity by 1995 to 2001 was in rectal screening (a procedure
not recommended by the U.S. Preventive Services Task
Future research should try to understand what might account
for this improvement so as to perpetuate its benefits.—Maria
Silveira, MD, MA, MPH, and Eve Kerr, MD, MPH, Ann Arbor
VA Health Services Research and Development Center of Excel-
lence, Ann Arbor, MI.
1. Franks P, Fiscella K, Meldrum S. Racial disparities in the content of pri-
mary care office visits. J Gen Intern Med. 2005;20:599–603.
402 JGIMLETTERS TO THE EDITOR