Friday, March 21, 2014

Compassion Fatigue? Or Sometimes You Eat The Shark And Sometimes The Shark Eats You

I passed a pamphlet for a conference on Compassion Fatigue today and thought to myself: "Why haven't I ever encountered the term compassion in medical school or at any point in my medical or professional training?"  If you look it up in a real dictionary there seems to be multiple meanings ranging from:  "A feeling of wanting to help someone who is sick, hungry, in trouble, etc."  to "a feeling of deep sympathy and sorrow for another who is stricken by misfortune, accompanied by a strong desire to alleviate suffering."  None of these definitions seems to capture what happens in medicine and how physicians are trained.  It seems like an undisciplined emotional reaction to human suffering.  That may seem a bit calloused to someone outside the field but would you want your surgeon operating on you in the throes of an emotional reaction?  Would you want your internist or psychiatrist recommending  medication for you during an emotional episode?  On the other hand, depending on what part of the definition I focus on,  I have already pointed out that in my opinion the overprescribing of medications is motivated at some level by "a strong desire to alleviate suffering."  More evidence that compassion may not be the best basis for medical decisions.

I can still recall the first patient that I was responsible for.  The very first patient I evaluated on Internal Medicine as a third year medical student.  He was not much older than me, but at that point he had a much harder life.  As he explained his symptoms to me and we did the examination, I found myself getting more and more anxious.  I realized that he had a very serious illness that he was not going to recover from.  I pulled all of the test results and x-rays together so I could present it in our team meeting in the morning.  I could barely get the information out to my chief resident and attending.  I was overcome with emotion.  My voice cracked.  I was tearing up.  My head was spinning.  I was focused on how unfair life was.  He was a young guy, just like me with the usual hopes, dreams, and relationships that we all have and through no fault of his own, he had developed a terminal illness.  I certainly wanted to help him, but there was nothing that could be done.  That happens so frequently in medicine, using the most emotional definition of compassion would render most physicians nonfunctional.  It tends to alter your focus.  The focus has to be on what is happening right here and right now and not the unfairness of the process.  The focus needs to be on the technical details or you can't provide competent care and tell people what they need to know.  As I have gotten older, I have an image for the process of unpredictable disease and death.  It reminds me of the war movie where the fleet is sunk and everyone is bobbing in the Pacific Ocean wearing life preservers.  Suddenly the sharks appear and people start to die on a random basis.  Whoever the sharks decide to kill.  A random horrific process.  That is my image.

It may explain the reaction of one of my attendings when I was a resident on a busy inpatient psychiatric unit.  I was reading the description of one of our consultants to him and the consultant used the adjective "unfortunate" to describe all of the medical problems the patient had sustained.  My attending glared at me and said: "Why is he unfortunate?"  It seemed like an obvious descriptor to me.  Anyone with all of these severe medical problems could be described as unfortunate, but I could not respond to him at the time.  It seems to me if the sharks get you or there is a near miss, unfortunate in the bad luck sense may be a good description.  He may have been thinking of another definition.  But I think he was most likely giving me the message that it is best to not even recognize the random walk through life and the fact that the shark can eat you at any time.  Without that element of denial, how can you function?  How can you function as a physician?

After you have talked with thousands of people about their traumas and adversities, you realize that most people suffer.  Personal biases make some people want to alleviate the suffering of some more than others.  Nobody wants to see children suffer.  There are some people who attract the ill wishes of others.  They are generally unlikable or they have perpetrated some kind of shocking crime.  There seems to be a likeability bias with compassion and that also makes it less useful for physicians.  Physicians are obliged to perform competent medical care irrespective of how well the person is liked.  There are often errors on the side of people who are very likeable.  Sometimes physicians and medical staff get very attached to  person based on their personality, physical characteristics, or demeanor.  You may want to help that likeable person more, but that doesn't translate into whether you can or not.

If you are trained to render assistance, save lives when you can and alleviate suffering where does the compassion that you had before medical school go?  Without invoking defense mechanisms it gets converted to other things that are adaptive in the profession.  Empathy and technical skill are good examples.  Empathy is probably a more accurate emotional appreciation of what is occurring in a person you are trying to help.  It is focused on that person and their emotional state and if reflected back to that person they would agree with the observations.  A better measure of burnout for physicians especially psychiatrists would be empathy fatigue rather than  compassion fatigue.  Seeing people as collections of symptoms and having no appreciation for the emotional side of their experience would be one example.  Seeing patients as an endless stream of problems that you need to fix rather than unique individuals would be another.  As the days get longer there are also the comparisons physicians make about how much time they spend taking care of others compared to how much time they spend with their families.  As the family time gets shorter it may be harder to empathize with increasing numbers of patients.

Whether it is compassion fatigue or burnout, these seminars all seem to teach the same things.  It is fashionable to refer to the skills as "tools".  Mindfulness techniques, cognitive behavioral therapy. relaxation techniques, meditation, diet, sleep, and exercise are all parts of the "toolkit."  Nobody ever seems to address the severely deteriorated work environment as a cause and ongoing factor.  Productivity demands on physicians in terms of the number of patients seen, the amount of documentation that needs to be done and the other aspects of being a good corporate citizen are a recipe for burnout and that is probably the most common job scenario for physicians these days.  Professional organizations seem to ignore that fact that if physicians are going to function the way they should and treat the whole person, a work environment without adequate time to talk with patients in one of the fast paths to burnout.

No amount of "tools" can reverse that.

George Dawson, MD, DFAPA

Supplementary 1:  In talking with people over the years and trying to help them stay on the job, the most significant problem is unreasonable employers.  People work in jobs where the job directly impacts their health.  The best example is alternating shifts and never being able to establish a regular sleep routine.  Hospitals are some of the worst offenders.  They have adopted policies that allow them to tell nursing staff that they need to work "mandatory doubles" when there are shortages.  The policies that have hospitalists working 7 days on and 7 days off are no better.  I have interviewed hospitalists about their cognitive efficiency on day 6 and 7 and have been told that it generally plummets.  They are taking twice as long to do the documentation and it is difficult to think.  I was in a similar position one year when I was running a 20 bed inpatient service with assistance of a physician's assistant.  I had to see everyone, everyday and managed both the medical and psychiatric diagnoses.  When I decided to stop doing that, I was replaced by two full time psychiatrists and an internal medicine specialist to take care of all of the medical problems.  Eventually those two psychiatrists felt it was too much work and a third psychiatrist was added to cover 4 of the 20 patients.  The adverse effect of a business model on employee health that operates on personnel expenses cut to the bone can not be overemphasized.  Hospitals and clinics will happily work medical staff to the point that it adversely impacts their health and lifestyle, adversely impacts their cognitive abilities at work, leads to burnout, and leaves them in a state where empathy is a thing of the past.

The only reason I quit running a 20 bed inpatient unit by myself was a colleague of mine who told me he did it for years - right up to the point he had his first heart attack.


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