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
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.
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.
- 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!”