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    Compassion Fatigue: The Toll of Being a Care Provider


    Too much paperwork, too many long shifts, too little time to sleep, exercise, or relax with family and friends. These stressors can push physicians into early retirement, career changes, cuts in practice hours—or compassion fatigue.

    Compassion fatigue can be the result of physical, emotional, and spiritual exhaustion from the demands of being a physician. “It’s a feeling of ‘I can’t connect with patients anymore,’” explained Oana Tomescu, MD, PhD, associate professor of clinical medicine and pediatrics at the Perelman School of Medicine, University of Pennsylvania.

    “Everybody’s at risk. I see it consistently in health care providers,” said Kate G. Sheppard, PhD, RN, FNP, PMHNP-BC, FAANP. About 10 years ago, Sheppard, a clinical associate professor at the University of Arizona College of Nursing, observed new nurses in emergency rooms who were excited, enthusiastic, and engaged with patients. The nurses who had 20 to 30 years of experience were detached by comparison, she said, “like they were going through the motions. They had built walls to avoid the hurt [of witnessing suffering, trauma, and death].”

    Since then, Sheppard has conducted studies on health care providers with compassion fatigue and treated physicians and nurses with the symptoms. Sheppard dislikes the term “compassion fatigue” because she found in her research that it implies that a provider no longer cares. “But people don’t lose compassion,” she noted. “Most still want to make a difference.” Sheppard prefers the term “professional emotional saturation,” which she describes as a combination of burnout and secondary traumatic stress.

    Emotional walls

    Compassion fatigue is related to but different from burnout and secondary traumatic stress, Sheppard explained. Burnout comes from the external environment—fast-paced working conditions, long hours, insufficient time to spend with patients, constant typing of medical records into a computer.

    “It’s critical to realize that this epidemic [of compassion fatigue] is a shared responsibility. Individuals are not going to ‘resilience their way’ out of this. The medical system and culture of medicine have to change.”

    Oana Tomescu, MD, PhD
    Perelman School of Medicine, University of Pennsylvania

    “Burnout is an accepted part of the job, but what pushes a provider into secondary traumatic stress is the feeling that they can’t take it anymore,” Sheppard continued. Secondary traumatic stress comes from within, such as beating yourself up when a patient dies. Or it can be a response to witnessing another’s grief or tragedy. “That’s when some providers build emotional walls to protect themselves,” she said.

    Depersonalization is yet another component of compassion fatigue.

    “A certain amount of detachment is needed for a physician's objective functioning ... [as] a protective coping strategy,” said Tomescu. If this detachment becomes extreme, though, physicians lose the ability to connect at all with patients. That’s when cynicism and jadedness can set in, she noted.

    “It’s critical to realize that this epidemic [of compassion fatigue] is a shared responsibility. Individuals are not going to ‘resilience their way’ out of this. The medical system and culture of medicine have to change,” Tomescu stressed. She said that pressures on physicians to see more patients and to discharge them from the hospital quicker has created “fast medicine.” “Like fast food,” she added, “it’s deadly. It drives burnout and compassion fatigue.”

    Keith Horvath, MD, senior director of clinical transformation for Health Care Affairs at the AAMC, agreed. “Like anything else, compassion can be taken to an extreme,” he said. “Physicians can care too much.” An unhealthy balance can further exacerbate this imbalance if the health care system demonstrates a lack of caring about the physician, he observed.

    Tomescu recalled her own experience as an intern: “After three or four rough, back-to-back rotations, I had a decreased sense of personal accomplishment. Whenever a patient or family was upset or angry, I found I wasn’t connecting with them. It was more and more distressing and led to a lot of self-doubt and self-criticism.”

    When a nurse said she’d want Tomescu for her own physician if she were critically ill, “that was the awakening to ask myself why my perspective of my competence was so different than another’s. I started focusing more on my own self-care, taking yoga again, and my burnout eventually became less severe.”

    A dose of self-care

    Today, Tomescu teaches a required course about physician well-being to medical students and residents at the Perelman School of Medicine and helps them develop strategies for dealing with compassion fatigue. “With more self-care tools, it can be reversed. Each person needs to find his or her own toolbox,” she said. Her current recipe for self-care includes a daily practice of “mindfulness, meditation, exercise, gratitude, and knowing what my mission and purpose are in my life.”

    “Many people who go into medicine are perfectionists. They don’t focus on the 9 or 10 things that went right but on the one that went wrong.”

    Romayne Gallagher, MD, CCFP, FCFP
    Division of Palliative Care, University of British Columbia Faculty of Medicine

    With a physician shortage facing the country, many medical schools and teaching hospitals are doing what they can to ensure that tomorrow’s physicians will be resilient and have long careers treating patients. Stanford University School of Medicine has had an MD Student Wellness program for several years, for example. And its E4C program (Educators-4-CARE [Compassion, Advocacy, Responsibility, and Empathy]) was established in part to address compassion fatigue as students mature in the MD program.

    Romayne Gallagher, MD, CCFP, FCFP, clinical professor in the Division of Palliative Care at the University of British Columbia Faculty of Medicine, said it’s a good sign that younger physicians are more aware of compassion fatigue and “are more conscious of work–life balance.”

    Gallagher, who has written about compassion fatigue for Canadian Family Physician, sees room for improvement, though. “Many people who go into medicine are perfectionists,” she said. “They don’t focus on the 9 or 10 things that went right but on the one that went wrong.”

    Gallagher’s advice to students is to “self-reflect and try to grow. See how you can improve the way you practice” rather than dwell on the negatives. “In residency, students watch colleagues who don’t deal with compassion fatigue, so they think that’s how to handle it—by avoidance or denial. They think that’s an emotionally safer way.”

    As a child, Julia Huber, MD, FACEP, watched her father burn out as a small-town, solo general practitioner who switched to an allergy and pulmonary practice. An emergency medicine physician in Kentucky, Huber chaired the national Well-Being Committee of the American College of Emergency Physicians (ACEP) from 2014 to 2016 and wrote a white paper for ACEP to spell out the signs and symptoms of compassion fatigue and suggestions for self-care. “We want to open up the discussion, promote the expectation of wellness, and promote physician resiliency,” she explained.

    Some people think they need to make radical lifestyle changes when compassion fatigue strikes, said Huber, “but that’s so far from the truth.” Instead, she suggests that physicians look at what’s most troubling about their situation. For example, are they working multiple shifts for financial reasons? “If it’s more important to spend time with family, they can say no to a shift and yes to a birthday party.”