Preventing Compassion Fatigue

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 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. We’d also gotten used 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? This may be one reason for so much burnout in fee-for-service medicine and why direct primary care seems to restore a physician’s ability to empathize. Doctors in fee-for-service practices simply care for too many patients.
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.

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