Françoise Mathieu (biography and disclosures)
What care gaps or frequently asked questions I’ve noticed
It’s early September, and I am standing in front of about 50 medical residents at a leading Canadian University. They are all in their final year of residency and are attending an orientation day meant to equip them for the next chapter of their lives.
“How many of you have received training on compassion fatigue and burnout?” I ask. Not one of them raises their hand.
“How many of you have received training in basic counseling skills?” One person raises her hand.
“How many of you have received training in working with patients with a psychological trauma history?” Again, silence.
The gaps in training among physicians on these issues are so wide that I don’t even know where to start.
When you started your medical training, were you told that you could potentially be permanently psychologically damaged by your job? Did your medical school instructors provide you with a toolkit to prevent compassion fatigue and vicarious trauma?
Compassion fatigue (CF) refers to the profound gradual emotional and physical exhaustion that helping professionals can develop over the course of their career. It eventually affects our ability to tolerate strong emotions and difficult stories in others, in both our professional and personal life. Compassion fatigue is one of the leading causes of suicidality, addiction, and burnout among physicians. CF can directly impact patient care, the climate in the workplace and family life.
Vicarious Trauma (VT) is a term used to describe the secondary trauma we are exposed to in the line of duty: graphic stories from the OR discussed in the lunch room, a colleague debriefing a devastating MVA (motor vehicle accident) in the ER, a patient telling us about the sexual abuse they experienced, working with refugees from a war-torn country – the traumatic stories physicians and nurses hear are innumerable. Over time, exposure to secondary trauma changes our view of the world – we can start having nightmares, difficulty getting rid of certain images, and can develop an intense preoccupation with a particular story or event we’ve been exposed to. It is a form of secondary post-traumatic stress that physicians can develop without ever having been in the line of fire.
Data that answers these questions or gaps
Work environment
Canadian work-life balance expert Dr Linda Duxbury has carried out research among health care workers which shows that, given the choice, four out of five of us would opt for more control over our schedule over a raise in pay.
Indeed, recent research has shown that the best way to reduce CF and VT is to work in a highly supportive work environment. This means having control over your own schedule, access to timely debriefing after a critical event, good quality supervision, and adequate training in working with difficult patients.
Self-care is of course always important, but the other factors mentioned above scored higher in the research in terms of prevention. To put it another way: all the yoga and massages in the world won’t protect you from VT and CF if you are working in a toxic work environment that is filled with high trauma cases and insufficient resources.
Training
One significant stressor is working with patients who are chronically decompensating emotionally: patients with chronic suicidal ideation, unrelenting chronic pain, constant family chaos, or intense psychosomatic complaints.
Patients who come across as manipulative and self-sabotaging can be extremely draining to work with if we don’t know why they are behaving in these puzzling and frustrating ways.
If you had the choice between helping one of these patients through the same crisis 25 times in a row or helping 25 different patients, which would you choose? Most of us find chronicity inherently depleting. The main culprit isn’t the patients’ behaviour; it’s our lack of training.
Here’s a case in point: In an excellent book called “The body bears the burden” American neurologist Dr. Robert Scaer discusses ways in which working with patients with whiplash syndrome completely changed for him when he understood the larger context of their symptoms – most of the patients who developed a debilitating set of reactions to the MVAs had a trauma history he refers to as “kindling”. The MVA unleashed a whole host of bottled up traumas which in turn manifested themselves as a series of physical symptoms. The MVA rekindled the fire, so to speak. Dr. Scaer said that understanding this phenomenon deepened his understanding of why his patients behaved the way they did, which in turn helped him remain compassionate and able to offer better care – without burning out.
What I recommend (practice tip)
Here’s the good news: some of the strategies to reduce compassion fatigue are easily within reach, but others may require some changes to your practice. In addition to getting more training and better control over your schedule, the top five strategies are:
1) Practice mindfulness meditation. Randomized control trials have demonstrated that mindfulness meditation is highly effective in reducing compassion fatigue among physicians. If you are unfamiliar with mindfulness, explore some of the resources mentioned at the end of this article.
2) Don’t self-medicate at the end of a long day. Alcohol, drugs, television, overeating, workaholism, gambling – these are all ways in which we numb out our feelings. Had a hard day at the office? Get some debriefing, work out, play with your pets, connect with your family.
3) Establish a support system/peer supervision that meet regularly and is also available for critical event debriefing as needed. Don’t wait for your employer to create this for you – pick two colleagues you trust and establish a supportive alliance with them. Join a Balint group.
4) Reduce your exposure to traumatic material in your leisure times: go on a media fast, turn off the news, use Low Impact Debriefing (see article below) with your colleagues and loved ones.
5) Get help before it’s a crisis: Burnout and depression are often taboo subjects among physicians. Consider using your provincial medical association’s physician wellness referral program. Find a therapist you trust in your community or consider telephone counselling with someone from another city if you wish to have added privacy.
Compassion fatigue is a normal occupational hazard, not a disorder, and it exists on a continuum in nearly all health care professionals. It is important to develop a self-monitoring process whereby each professional can learn their own warning signs and self-monitor regularly before they tip into what we call “the red zone” when burnout looms.
References and/or Additional reading (View with UBC credentials or request from CPSBC Library)
- Bober, T. & Regehr, C. Strategies for reducing secondary or vicarious trauma: do they work? Brief Treat Crisis Interv. 2006; 6(1):1-9 (View article)
- Duxbury, L., Higgins, C., & Lyons, S. (2009). The etiology and reduction of role overload in Canada’s health care sector. Workplace, Safety and Insurance Board of Canada. (View book)
- Kearney, M.K., Weininger, R.B., Vachon, M.L.S., Harrison, R.L, et al. Self-care of physicians caring for patients at the end of life. Journ Am Med Ass. 2009; 301(11): 1155-1164. (View article)
- Killian, K. Helping till it hurts? A multimethod study of compassion fatigue, burnout, and self-care in clinicians working with trauma survivors. Traumatology. 2008; 14(2): 32-44. (View article)
- Mathieu, F. (2012). The compassion fatigue workbook: Creative tools for transforming compassion fatigue and vicarious traumatization. New York: Routledge. (View book)
- Richardson, C. (1999) Take Time for Your Life: a 7 Step Program for Creating the Life you Want. New York: Broadway Books. (View the author’s website)
- Scaer, R. (2007) The body bears the burden: Trauma, dissociation and disease. New York: Routledge.
Resources:
- ProQOL (professional quality of life) self-test: http://proqol.org/uploads/ProQOL_5_English_Self-Score_3-2012.pdf
- To view a free video on Compassion Fatigue and Vicarious trauma https://compassionfatigue.ca/video-the-basics-understanding-compassion-fatigue-and-vicarious-trauma/
- Low Impact Debriefing https://compassionfatigue.ca/low-impact-debriefing-how-to-stop-sliming-each-other/
- Mindfulness meditation as a tool for compassion fatigue: http://compassionfatigue.ca/?p=306
- Selected bibliography – Compassion Fatigue in Palliative Care physicians: http://compassionfatigue.ca/?p=2382
- BC physician’s help line: http://www.physicianhealth.com/, 1-800-663-6729 (available 24/7).
Signs of Vicarious Trauma
- Intrusive images/nightmares from patient stories, that last more than a few days
- Difficulty getting rid of a certain traumatic story, thinking about it repeatedly
- Change in world view – finding it difficult to enjoy every day activities, without thinking about trauma (e.g. every bruise you see on a child is potentially leukemia, for an oncologist, or seeing a motor bike and immediately thinking acquired brain injury, hypervigilance about your children’s safety due to trauma stories you have seen in the E.R., etc)
- Exposure to traumatic stories that interfere with your sexual intimacy with a partner (due to exposure to sexual trauma, for example)
Signs Compassion Fatigue
- Profound emotional exhaustion
- Desensitization or loss or empathy toward patient stories
- Poor bedside manners
- Avoiding telling patients difficult news e.g. delegating a death notification, due to profound emotional exhaustion
- Loss of compassion and empathy for our loved ones “you think you’re sick? I’ll show you a real sick person!”
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I consider myself very fortunate that my family medicine residency in Santa Rosa, California incorporated both a psychologist-led peer support group for interns, and a mandatory Balint group for the R2 and R3 years.
What is a Balint group? Is EMDR a useful alternative?
I learned from this seminar to establish a support system and practice low impact debriefing
I am also a senior FM resident in the US (it is three years here) and I find the timing of this quite interesting, as I recently wrote a small piece (which may appear in a local medical publication) reflecting on compassion fatigue and burnout.
Working in a severely underserved area, we are often told by our program and staff that we should take care of ourselves, but there is no true support from them in this regard. Like the first commenter, we, too, have several behavioral staff on faculty. I have had multiple experiences with tearful peers coming to me, on the verge of breaking down. In hindsight, I have had increasing symptoms of burnout since late in my first year of residency. Nine months of Q3 call in intern year alone, while taking care of a medically and socially complex population and being thrown under the bus by staff can be draining.
To the previous generation(s) that did Q2-3 36-48-hour calls, I have an enormous amount of respect for you and how you made it through those times. Having not had a 48-hour call since my days as a medical student, I don’t know how you did years of that. But, the daunting challenge of understaffing persists. One such challenge I can recall from earlier this year was (attempting to) managing four actively laboring women while also doing eight medicine admissions (each admitted for no fewer than five acute issues, aside from their page-long list of chronic comorbidities) with/for my intern (who knew little and actually shed tears several times throughout the call) and “supervising” the same intern while they managed an inpatient medicine census of 30 patients (4-8 of whom were critically ill).
I believe I have suffered from compassion fatigue during my 42 years working in health care, first as an RN for 18 yrs, then as a family doctor.
I wonder if women suffer more from compassion fatigue. I suspect women develop more empathy for patients, and therefore vicariously “take on” or experience the suffering.
I was unable to locate any Balint groups in Vancouver, BC. I would definitely have joined one.
I do feel “burned out”. I have no more energy or resiliency, to provide care. I retired one year ago, 5 years sooner than I intended to, because of this.
Having a few people for support, is not very realistic. My spouse and my best friends did not want to hear about the reality of my work stressors. Peer colleagues also did not have time for this. The pace at which one must provide care is also stressful. Hospital crowding, wait times, these issues are so out of one’s control.
@DavidB Balint groups originated in Europe in the 1950s and were originally aimed at general practitioners wishing go explore patient/doctor relationships. It is a grouping of physicians who meet regularly (e.g. monthly) to discuss and reflect on the impact of their work. Here is more info:
http://balint.co.uk
http://americanbalintsociety.org
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3303639/
EMDR has indeed been found to be effective in reducing intrusive traumatic thoughts and images (related to indirect and direct trauma exposure) as have some tapping techniques such as Thought Field Therapy (TFT) and Emotional Freedom Technique (EFT) though I am not sure that there are RCTs (randomized control trial) studies for the latter two techniques.
As an instructor in a MN-NP program I will be working to find space in an already crowded curriculum to discuss this with students. It should be part of their preparation for practice. We already do some of this on an informal basis. This article has convinced me that we need to provide a more structured opportunity for discussion of this topic.
This was the 1st article that I’ve read in the series “This Changed My Practice”. I have been aware of these issues for a long time–ever since med school (UC San Diego ’76). Throughout my career, I have had numerous opportunities to choose between time and money. I’ve almost always chosen the time, and been very well-served by that choice. This substantially boils down to a couple of questions:
1. How much money do I need? For most people, the usual answer is, essentially, “A little (or a lot) more than I have now”. I learned very early in life that beyond a certain point, more money does not provide more happiness. More commonly, it provides less. I’ve felt vindicated in recent years by research indicating that, beyond an income of about $50K/yr. (stretch that out to $50K beyond med school debt servicing in the modern era of debt slavery), more money, indeed, does NOT produce more happiness. An illustrative question: “How much do you have to be paid to have a bad life?”
2. To what extent am I personally responsible for solving all of my patients’/all of the health care system’s problems? This one is harder. There will always be sick people there at the end of the day. There will still be system dysfunctionality (short-staffing, for example), too. Striking a healthy balance between “doing the right thing” and defending one’s boundaries will vary a lot from one person to the next, but the issue will remain under all conditions. I also think that making huge amounts of money tends to make some of us feel guilty if we’re not chronically over-working ourselves.
Well…that’s enough for now. I could go on about this for quite some time.
Comments?
Philipians 4:13 “I can do all things through Christ which strengtheneth me.”
I used to get compassion fatigue and burnout.
However, since I became a born-again Christian filled with the Holy Spirit, I have boundless support to give to these patients, even the really depressed, chronically suicidal types.
At the end of the day, it really does boil down to “Love your neighbour as yourself.” All these people want is just to be heard, shown that you care for them, and if you can uplift them spiritually with some kind words, all the better. I try and spend less time addressing the psychosomatic symptoms which I think as physicians, we tend to overmedicate for anyway, rather than addressing the underlying problem (which ultimately is distance from God)
Now here’s the kicker… if you can encourage them to pray, and feel the Holy Spirit for themselves, you will end up seeing them a whole lot less :) God is the ultimate counsellor :)
What I speak of works, and God is very real.
I recently came across this excellent article and find it very heartening. I don’t recall receiving any training of this sort during my residency in the 1980s. I spent the first part of my career working in a wonderful group practice in Southern Ontario, which was very nurturing. However, since moving to the Vancouver area and finding myself running a semi isolated solo practice, I am feeling the loss of support more and more. Truly, these daily stresses do accumulate silently, until an incident makes you aware of the burden you have been bearing. I would be very interested in finding a Balint group in the Vancouver area.
Glad to see this issue getting the attention it needs.
re: Meditation: I highly recommend checking out the Mindful Practice work of Ronald Epstein, Michael Krasner, and colleagues at University of Rochester. Ron’s book “Attending” is a masterpiece. At BC Children’s and Women’s Hospital we are doing a mindfulness course for MD’s, modified from the Rochester model. I wrote more about this for UBC Postgrad: https://postgrad.med.ubc.ca/2017/03/17/staying-present-mindfulness-in-health-care/
One thought to consider: Is “compassion” and “empathy” the same thing? Is “compassion fatigue” actually something more like “empathic distress fatigue”? (Klimecki et al 2012)
re: Balint Groups: There are a few people trained in this in BC. My division (Adolescent Medicine) is about to start this for our group. Hopefully there will be more opportunities for this.
Dzung Vo, MD
Division Head, UBC & BCCH Division of Adolescent Health and Medicine, Dept of Pediatrics
Dear Dr. Vo, thank you for your comments and resources! I agree with you that “compassion fatigue” is not the accurate term for this phenomenon, and that it is best defined as empathic strain. The field still has a long way to go to improve clarity on nomenclature. Some of my colleagues and I who are specialists in the field have created a think tank to further explore best practices and improve research (www.stsconsortium.com) and will be producing some best practice consensus guideline recommendations in the year to come. Thank you for your insights and input! Warmly, Françoise Mathieu