Preventing Compassion Fatigue

Photo: o5com

I vividly remember the first day my medical school classmates and I met our cadavers in the anatomy lab. Large body bags lay on metal tables that had been bolted to the floor. I remember the sheer size of the bags best. No doubt existed in my mind that dead human bodies indeed lay within them. And yet part of me couldn’t quite grasp that I was actually going to soon be unzipping them and cutting into flesh through which blood had once flowed as freely as it now did in mine. I vividly remember also a classmate of mine—one who’d struck me as being particularly sensitive to others—leaning against the wall at one point, looking pale and shaky. I remember worrying that she was going to faint.

But she didn’t. And like the rest of us, soon she was cutting into her cadaver with focused precision. Within only one week we all had habituated to the notion that we were dissecting dead people as if they were only mannikins, as well as to the smell of the preservative in which our cadavers had all been soaked. Even on the most bizarre day of our anatomy experience—the one during in which we had to saw off our cadavers’ legs, carry them on our shoulders to the lab’s sinks, and wash out the leftover detritus—none of us became woozy or even emotionally disturbed by what we were doing at all.

My classmate eventually went on to become my colleague, one with whom I’ve since shared many patients. And though technically she was always excellent, again and again it would get back to me from patients to whom I’d send her that she had a poor bedside manner. And whenever I’d hear this, I’d wonder: had she always been only peripherally interested in the suffering of others (as more than one of my patients judged her to be) or did she begin as empathetic and compassionate as I’d first judged her and simply have those characteristics pounded out of her by her training and subsequent years in practice?

THE BENEFIT OF COMPASSION

The scientific literature is full of studies demonstrating the benefits of compassion, not just to those who receive it but also to those who feel it. Compassion is considered a great virtue—perhaps the greatest—something most of us aspire to feel in abundance. Yet feeling it is surprisingly hard. There are many reasons for this: people annoy, anger, disappoint, and hurt us; we’re inherently self-interested beings whose desires often come in conflict with the desires of others; in caring for others and attending to their needs we often neglect ourselves and become resentful, projecting our inability to set appropriate boundaries onto others. We’re also all so busy, so focused on what we have to do next, that often we don’t stop when we could to help someone else. After all, doing so represents an interruption in our day, and perhaps even might prevent us from accomplishing important goals.

But perhaps the most insidious force that gnaws away at our ability to feel compassion is habituation. We have an amazing ability to get used to things—meaning that if repeated again and again something which at first stimulates great emotion (positive or negative) progressively stimulates that emotion less and less. This is why, I think, over time my colleague’s bedside manner deteriorated: she simply got so used to the suffering she saw day in and day out that it ceased to trigger her compassion (or triggered it far less, or far less consistently). I’ve experienced this myself: when patient after patient comes to you in horrible pain, it can start to feel routine. Further, doctors often have difficulty imagining the subjective experience of illness (most of the time not being sick themselves), so when confronted, for example, with a patient’s minor backache, we’re more apt to treat it perfunctorily, especially when another patient we might have seen that morning was suffering from unbearable, debilitating bone pain due to metastatic cancer.

So, how can we consistently maintain our compassion for others?

  1. Strive for greater balance. If we’re constantly overwhelmed by the number of tasks we have to perform, being able to prioritize someone else’s pain becomes much harder. If we don’t leave room in our daily lives to be interrupted by someone else’s emergency, just how important are the lives we’re struggling so hard to live?
  2. Deal with your own problems first. If we’re anxious, sad, depressed, angry, preoccupied, or otherwise self-involved, how can we ever remove our focus from ourselves and aim it at someone else?
  3. Take the time to learn about the stories of others in detail. No matter how stressed I am at work, no matter how much pain I’ve witnessed earlier in the day, when a person sits down in front of me and tells me what they’re going through in detail, I’m always moved. Why? Because stories move us. It’s one thing to hear someone say, “I’m not doing so well,” but it’s another entirely to learn their son was recently murdered and their daughter has leukemia. Writers are told show, don’t tell for a reason: what invokes emotion in us are stories with which we can identify. Listen the stories others have to tell you.
  4. Constantly remain on guard against the impulse to label people. We tend to abstract others into functions and labels for a variety of reasons. But our mail carrier doesn’t just deliver our mail. She’s also a mother who’s worried about her daughter with severe asthma because she can’t afford to buy her medicine every month.
  5. Remember the principle of dependent origination. We are all far more tightly linked than we commonly realize. We think someone else’s problem is theirs, not ours, but the more we bother to be a good influence in the world, the better place the world will be not just for others but for us.

Eventually I stopped referring patients to my former classmate. The picture my patients were painting of her was simply too consistent. I was sad about this—not so much because I’d lost a valuable resource, but because her experiences in medicine seemed to have stamped out something in her that was important, that once, I’m sure, mattered as much to her as it did to her patients. I wondered how aware she was of this change. I wondered how often I’d been guilty of the same thing. In the end, I resolved to use her as an example, as a warning: even for those of us who fight every day to maintain our compassion, it’s an all-too-easy battle to lose.

Next Week: Learning To Enjoy Things

15 comments to Preventing Compassion Fatigue

  • chris

    #2 (paraphrased)
    Take as good care of yourself, so that your “bucket” is “full,” as you take of your patients. If your own bucket is empty, you have nothing to give.

  • chris

    People who have compassion fatigue or burn-out are not only irritable, feeling and acting like a raw nerve, but they are also exhausted and have become numb. They are drained. They may have nothing left to give their families at home, nor their friends. It can be a dark-night-of-the-soul.

    Helping and care-giving professionals must guard against spreading themselves too thin—which is perhaps a corollary of your #1, Alex. Too many patients? Too little time per patient? It has to stop. You just cannot do justice under such circumstances.

  • Ellen

    I understand why doctors have to emotionally detach themselves from patients in order to provide quality care. It’s hard to be objective when overwhelmed by compassion. That’s why doctors should not treat their own family members. But there is a difference between detachment due to fatigue and abuse of a patient due to fatigue. Blaming the patient is never acceptable when the patient has a difficult-to-diagnose painful condition. Your posts are excellent, but I fear you are preaching to the choir. And what can patients do, because reporting the abuse results in either stonewalling or more abuse. This might be a good topic for one of your future posts….

  • Sheryl

    Well said!

    I have found that being compassionate fills us with a sort of light, or fullness of life.

    I have also found that the more one practices, the easier it becomes, the more automatic the connection and response.

    I think, though, that I have a problem with being too compassionate, especially with my family members. My friends enjoy my compassion because they don’t have it in their face every day, but I have a hard time turning it off around my kids.

    It is a bit overwhelming when I’m constantly “feeling” for everybody. It becomes habitual and too automatic. Even just now as I am supposed to be having “my own time” and my kids are vying for my attention. I want to connect with them and help them feel better, but I also want to be free of their needs and have my own space.

    Sheryl: I think this is one of the great challenges of living a compassionate life: when to make your own needs a priority. Not an easy line to walk.

    Alex

  • Ana

    I appreciate that this post is not specifically about patient care, per se, or even about the special doctor-patient scenario; it’s about all of us—patients, doctors, students, mothers, educated, non-educated, literate, non-literate…any of us who falsely believe that each of us is uniquely unique in our uniqueness. We’re not. We’re all…connected by our common uniquenesses, and that connectedness mindset will help nourish—and maintain—our compassion. Thanks for reminding us that not only are we our sisters’ and brothers’ keepers; we ARE our sisters and brothers. 🙂

  • Paul Myron RPh

    Alex, don’t you suppose that this physician developed this personality as a coping mechanism to be able to function through the day and overcome her fear of failure? If only she had learned a better way I’m sure she would have been a more caring, confident doctor. I have met many physicians who have been empathetic and caring. Almost all were older. I’m not sure if this caring attitude comes with long experience, or were different types of training used back in the day to insure that this was part of a well rounded physician? My perception is that young doctors that I met in the 80s and afterwards, seemed to be all business and less “human” in there dealings with their patients and colleagues.

    Paul: You may be right. I honestly don’t know. I think people lose their sense of connection to people, their empathy and compassion, for many different reasons in the health care industry. The reason I gave in the post was only my best guess.

    Alex

  • Lila

    Alex,
    I always look forward to reading your posts and often forward them to a few “like-minded” friends. My mother (now 91) has a doctor whose “bedside” manner declined for about 6 months, and while he always seemed professional and skilled I was wondering if we should look for another doctor. Someone suggested that maybe he was experiencing “burnout,” a thought that honestly had never occurred to me. One visit, he returned “back to his old self” (or maybe new self). I thought maybe a vacation or retreat had helped renew. The one thing that I am wondering about is that you chose to stop referring, but did not (as you mentioned the possibility of lack of awareness on her part) try to gently help her investigate this possibility (as a colleague). I realize there may be other factors, but it seems that this gesture may be been compassionate as well.

    Lila: You’re exactly right. I considered giving her feedback, but given that around this time she moved her practice and that previous discussions with her about other matters left me with the feeling that she wasn’t particularly open to such feedback, I never did. In retrospect, I think I should have anyway for the very reason you point out.

    Alex

  • I must agree that to be a true “healer” one must be more than an accurate diagnostician and technician. Although these are meaningful skills, they do not touch the soul the way true caring does. We are not just flesh and skin encapsulated bodies, like cadavers. We hold the energy life force inside of our beings, along with fears, thoughts, memories, feelings, hopes and dreams. There is no place for ego in true healing.

  • Hi Alex,

    Having just written a post on compassion and the latest neuroscience, I am delighted to see this article. Great points, especially the emphasis on self-compassion. Based on experience and the latest neuroscience, I believe they are strongly correlated.

    I think your point on habituation leading to fatigue is a really important. As you probably know studies show the correlation between lack of empathy and distraction.

    Research subjects who under normal conditions would display empathy, are less prone to do do when their attention is distracted by their immediate objectives. This reinforces your third point—taking the time to focus on the other person or situation. To do this we must consciously bring our awareness to the other person—and to whatever we are feeling—anxious, worried, rushed, frustrated, etc.

    Thanks for a very well done article!
    Louise

    Louise: I liked your article.

    Alex

  • Danny

    In a college karate class I was in, the class began by a minute of silence which in part was meant to separate the outside world from the inside world, allowing one to focus only on the karate class. This was in spring ’93. It seems like sometimes we should try to separate our worlds to allow for focus.

    In many companies the push for longer hours for salaried employees has forced many people to mix home life and work life considerably. Taking work home and thus having to manage home life that was pushed out.

    I don’t know the last time I have seen more than 3 people focus on any one thing. Now it is probably impossible to tell how much workload has truly increased and how much productivity and joy in focus and achievement has decreased. Maybe we can find flow in answering X number of emails per 5 minute interval.

    First time commenting, many time reader. Thanks.

    Danny: Glad to have you here. We are all overworked and often as a result have a hard time focusing on any one task. Taking one thing at a time has indeed become a skill that requires practice.

    Alex

  • Thanks Alex,

    I’m interested in your book—plan to pick it up.

    All the very best with it,
    Louise

  • John Markovitz

    Thanks for your article on fatigue. In my practice, I like to remember to “breathe,” even just for a few moments as way to center myself for the next patient.

  • 001mum

    It’s tough for me have a relationship with myself. Feelings of guilt drilled into me by an (now 95-year-old mother) as well as a spouse (who would never ever take a vacation without the kids or sleep with the door closed); add to that being an extraordinarily sensitive Registered Nurse who often skipped breaks, my very core was blistered. Fabulous mental health care has over 6 years helped me to understand that I am important. There is always balancing needs and wants and whines. In my everyday life I have a “relationship” with numerous people (and that includes other car drivers in hectic traffic, waiting in a grocery store line,entering the escalator line-up,helping a co-worker or truly listening to a very anxious new patient) and what now works for me is “the moment.” I focus on the request/need/want and help as best I can.

    Giving myself “treats” such as new socks, a down pillow, my favorite dark chocolate, a soaking hot bath, or a walk in a field helps me to be less anxious and more effective with other people.

    **but I have to remember to take for myself and work hard at it every day**

    P.S.—my day off, supper is not ready and I didn’t apologize. It’ll get that done as soon as I finish this post! 🙂

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  • Elle

    If I may add something: in my experience, often one’s capacity for compassion can be either enabled or obliterated by how one has been treated by “the world.” I’m presently an ABD (all-but-dissertation) in a science field (physiology)—a situation in which abuse/bullying is built into the academic culture. I found that during my worst times, when everyone around me was either difficult or outright hostile/abusive towards me, I also became hostile. I figured I would “give as good as I got”, and even found it to be necessary, for a time, to get things done. But once I’d weathered that, I realized how wrong that attitude was and how horrible it left me feeling. I’ve since determined that I will not stoop to such attitudes and behavior, and I decided to act with integrity and compassion regardless of what others around me do. In adopting this attitude I have not only cleansed myself of a counterproductive mindset, but I also feel so much better, even on bad days. It allows me to detach, be more objective when facing bad situations because I don’t let myself become entangled in negative emotion. But then again, I’m also not faced with life and death daily, as are physicians/interns/residents/nurses. I think that is a whole other situation that certainly is more complicated and more difficult by orders of magnitude.

    There is a blog post that discusses some of these points at: http://well.blogs.nytimes.com/2012/08/09/the-bullying-culture-of-medical-school/

    Thank you for offering your insights and some solutions Alex. Your blog has become essential reading for me!

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