By Tandi Wilkinson (TW) MD CCFP-EM FCFP (biography and disclosures) and Shireen Mansouri (SM) MD CCFP-EM FCFP (biography and disclosures)
What we have noticed
We are hearing from many of our medical colleagues about their distress in this time of COVID-19. Many are troubled by the fact that most of the people admitted to hospitals and intensive care units are not vaccinated. Also upsetting are protests, directed at health care workers, against the vaccine and public health restrictions. Faced with yet another variant and uncertainty, we hear that our colleagues are exhausted, frustrated, and angry.
Both authors, being interested in supporting physicians to thrive in their work, have been studying compassion and its role in practitioner well-being for the last few years. As looking at this issue (and other challenges of the pandemic) through the lens of compassion has been personally helpful to both of us, we wanted to share our learnings with you.
Key insights
- Compassion is innate, AND it can be cultivated and strengthened.
- Compassion is a recognition that suffering is present, a feeling of caring and connection towards the person who is suffering, and a desire to alleviate the suffering.
- Compassion is a lived experience, felt in the body and not just intellectually.
- Compassion can be directed towards others, towards self, and can be received from others.
- Health care practitioners often struggle with self-compassion and receiving compassion.
- Compassion does not require you to change your beliefs. Instead, it understands that other people may prioritize different values, for instance, the value that we as individuals have the right to determine what goes into our bodies.
- Bringing compassion to the conversation can create the possibility for more deeply understanding both sides of a polarized debate. It creates the possibility of tolerating differences and making room for everyone. Demonstrating compassion opens doors to communication and connection, and builds relationships.
Early in the pandemic, I (TW) decided to drop my judgement of anyone for the decisions they were making regarding masking and vaccine choices. I chose to believe that most people were doing what they thought was best for them. I didn’t need to agree with those decisions, but I didn’t want to be judgmental either. I just felt like that was energy that I did not have and I wanted to focus on remaining equanimous through a difficult and scary time as an emergency medicine physician.
Practice tips
Acknowledge Your Own Feelings and Experience First
To cultivate compassion for the people who are not vaccinated, acknowledge your own feelings about this issue. Have you felt angry? Hurt? Do you feel like some of your core values are being violated? Spend some time allowing your feelings to arise. Name each of them. “I feel angry.” “I’m exhausted.” Allow each feeling to be there without judgement. Your feelings are valid. Cultivating awareness of our feelings, naming them, and allowing them, takes away some of the power they have over us. We are not eliminating our feelings, but cultivating a relationship with them that is less draining for us.
Practice Self-Kindness
Show yourself some warmth and love for what you are experiencing. Dr. Kristin Neff, a researcher in self-compassion, describes a self-compassion break exercise that includes these three steps:
- Say to yourself “This is a moment of suffering.”, acknowledge that your feelings are difficult to be with.
- Remind yourself that you are not alone.
- Show yourself some kindness. Treat yourself as you would treat a good friend.
Seek Common Ground
Draw on the concept of common humanity, which understands that as human beings we all have a desire to be happy and free of suffering. We all know people who are not vaccinated AND are kind, considerate human beings. They are partners, children, friends, and loved ones. Observe, and then drop, any tendency you might have to label or make assumptions about people who are not vaccinated. They are just people, like you and I, with varied reasons for choosing not to be vaccinated. Creating a situation of ‘us’ and ‘them’ is the first step to dehumanizing a group of people. Common humanity acknowledges that we all have fears, hopes, and joys. Not being vaccinated is only one aspect of a complex personality and life experience. Separate the person from the action. We can disagree with the action but still respect the person. Pay attention to language. Say ‘a person who is unvaccinated’, not ‘the unvaccinated’. Creating a feeling of common humanity can be as easy as picturing the mother or father who loves this person.
Seek to Understand
In conversations, seek first to understand, rather than be understood. Consider what it might be like to be a person who is unvaccinated right now. There are more social restrictions, possible loss of employment, and many remain socially isolated. Many are living with fear of the vaccine and of the disease. For someone to choose this path over being vaccinated suggests they have strong reasons for doing so. They are standing up for what they believe to be true for them. Have you ever been certain you were right about something, made a personal choice on something because it was right for you? Get curious about why the person in front of you is not vaccinated. What are their fears? What are their barriers? Seek to understand it from their perspective.
I (SM) decided to ask people “What are your thoughts about vaccination?” The responses were as varied as the people I asked. I found listening to their stories gave me another layer of information about who they were and their values, which added to the richness of my medical practice.
Seek to Do No Harm
Once you have listened and understood, you may have an opportunity to answer questions, share information, and offer your opinion. If it’s clear that your listener is not interested in your opinion, set it aside. Perhaps all you can do is not inflame the situation further. Sometimes the most powerful thing you can do is to allow someone to feel understood.
Seek to Relieve Suffering
Many people who are unvaccinated, are presently suffering from judgements being passed upon them. Seek to relieve that suffering to the degree that you are able. It might be as simple as having that curious conversation. Or just taking a breath before going in the room and remembering that this person too wishes to be happy and free of suffering. In medicine, we tend to measure our impact in cures and fixes. What if our impact is in how we show up and in how we make someone feel? It may be that demonstrating kindness and acceptance creates the possibility for future conversation and future care. We are starting to understand that just by making people feel seen, heard, and respected, we can change health outcomes. Don’t underestimate your impact.
We May Also Need to Relieve Our Own Suffering
Come back to ourselves and check-in. How do we feel now? If anger and frustration are frequently arising for you, this may be a signal of an unmet need. Sleep, nourishment, connection, or more time for yourself might be needed. The pandemic has changed the equation of how much rest we need to replenish and to continue working. Viewing our exhaustion not as a weakness, but as a sign of what we need more of, is the practice of self-compassion. Taking care of ourselves in order to show up as our best selves in the world is essential.
If after reading this, you find yourself unable to take any of these steps, accept that and just sit in compassion for yourself. You are okay, just the way you are. You are just like others in your desire to be happy and free of suffering.
Resources and Further Reading
Compassion Cultivation Resources:
Short Daily Inspirations:
- Wagamese R. Embers: One Ojibway’s Meditations. Toronto, OT: Douglas and McIntyre; 2013. (Find with WorldCat). Accessed December 2nd, 2021.
- Nepo M. The Book of Awakening: Having the Life you Want by Being Present to the Life You Have. Newburyport, MA: Red Wheel; 2020. (Find with WorldCat) Accessed December 2nd, 2021.
- Beattie M. Journey to the Heart. New York, NY: HarperOne; 2014. (Find with WorldCat). Accessed December 2nd, 2021.
- Kimberly Manning MD @gradydoctor on Twitter. (View). Accessed December 2nd, 2021.
Compassion:
- Brach T. Radical Compassion. Barcelona, ES: URANO;2019. (Find with WorldCat). Accessed December 2nd, 2021.
- Neff K. Self-Compassion. London, EN: Hodder & Stoughton; 2013. (Find with WorldCat). Accessed December 2nd, 2021.
- Jinpa, T. A Fearless Heart: How the Courage To Be Compassionate Can Transform Our Lives. New York, NY: Avery Publishing Group; 2016. (Find with WorldCat). Accessed December 2nd, 2021.
Burnout:
- Nagoski E, Nagoski A. Burnout: The Secret to Unlocking the Stress Cycle. London, EN: Vermilion; 2020. (Find with WorldCat). Accessed December 2nd, 2021.
Poetry:
- O’Donohue, J. To Bless the Space Between Us: A Book of Blessings. New York, NY: Doubleday; 2008. (Find with WorldCat) Accessed December 2nd, 2021.
- Oliver M. 1963–2017. Poetry. (Find with WorldCat). Accessed December 2nd, 2021.
Fiction:
- The Louise Penny Mystery series, featuring a compassionate homicide detective modelled after her husband, a Montreal pediatrician: Penny L. 2005–2021. (Find with WorldCat). Accessed December 2nd, 2021.
Podcast:
- Manning K, McMullen A. We are All Support Beams. The Human Doctor. 2021. (View). Accessed December 2nd, 2021.
Practices:
Cultivate Mindfulness:
- I love Insight Timer, a free meditation app. Tara Brach is a favorite instructor, especially her introduction to meditation.
Insight Timer [App]. Version 16.0.2. Sydney, NSW: Insight Network Inc; 2009. (View)
Compassion Cultivation:
- Self-Compassion.org (View). 2021. Accessed December 2nd, 2021.
- Compassion Institute. (View). 2019 Accessed December 2nd, 2021.
- Compassion Education Alliance. (View). Accessed December 2nd, 2021.
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This UBC series is usually awesome (including this one), thank you. Kristin Neff’s name is misspelled in the document. As a former student of hers, I can say that her work changed my “world” – thank you for summarizing her work (and for correcting the spelling).
This is a very helpful post, especially right now as we face all the threats and unknowns of a new SARS-COV2 variant.
I am no longer a front-line physician although I interact with women seeking information and advice and support daily through the Ask Us feature of the Centre for Menstrual Cycle and Ovulation Research website (www.cemcor.ubc.ca).
Wagamese’s Embers is one of my favourite books–his deeply spiritual and honest writing coupled with appropriate nature pictures and colours and shapes . . . .
As I read this post, I realized I was beating myself up for not accomplishing more, for the things I new see I will not live long enough to accomplish. I really needed the reminder to practice self-compassion.
Very helpful, thanks.
I love your compassion for me, the reader, “ If after reading this, you find yourself unable to take any of these steps, accept that and just sit in compassion for yourself. You are okay, just the way you are.”
A very relevant topic. While I do my best to be open and non judgemental to patients who are unvaccinated, inside myself I am having feelings of frustration and negative judgement. I appreciate the directive to acknowledge the feelings , give them space, and have self compassion. Also, appreciate the approach of seeing the unvaccinated person as a person who is suffering and who is doing their best, what they believe is the best thing for them or their children. And your suggestion that the way you “show Up” for patients can be healing in itself.
Thank you for this very thoughtful article
I think we need to be compassionate, but we are also entitled to feelings of frustration. We must remain sensitive to patients but also require appropriate outlets to express these frustrations. These outlets may include meditation, art, writing, music and sport.
just in time. My emotional distress during this time has been what we are doing to each other and how we approach patients with differing choices than our own. Thank you for brining this topic forward, we all need a reminder.
Thank you for this thoughtful article. One thing that is not being discussed enough is that there is a great deal of anger and frustration from all corners at the moment, not just from health care workers towards people who make choices we don’t agree with. Patients making choices we do not like is not new. What is new is the volume of patients who are angry and frustrated and taking it out on not just us but others. For example, many anti-vaxxers are angry with those who vaccinate or choose to get vaccines, and often not respectful of others’ choices. I have had many patients aggressively challenge me even when I have used the techniques you advocate – which are my normal way of relating to patients. I believe we will see many health care workers leaving their jobs for less stressful work over the next year, because the aggravation-to-reward ratio has become untenable in spite of mindfulness and compassion. This self-compassion being demonstrated by health care workers is already contributing to the system failure we are seeing in many areas of medicine.
I’m not sure if there is reason for me to discuss the immunization status of individuals who present to my ED critically ill with COVID-19. The vast majority of the time, the paramedic or triage nurse has already obtained that history. Even if their immunization status is unknown, it’s just not really a priority since their opportunity to be vaccinated in future is contingent on whether we can facilitate their survival during this acute insult. The treatment is the same whether or not they have been immunized previously. It variously saddens or annoys me to hear that they’ve met with the consequences of being unimmunized, and neither emotion seems productive or useful. Maybe it’s a missed opportunity for education but how much education could you possibly be open to with sats in the 70s?
For those who are stable & unimmunized, my willingness to broach the topic depends on the day. Sometimes I can be open and curious. Other days I just triage my own COVID fatigue and choose not to poke the dragon. I can only beat my head against that particular wall so many times per day.
Thank you for putting into words so many things that need to be said about compassion, compassion-fatigue and self-compassion. This article is useful as an approach to every patient ( or even every human) encounter that we have. The power of listening can not be over-stated. So often in my busy day I ignore this and get on with the seemingly necessary clinical work that ignores that there is a person behind the numbers. When you start from a place of open-ness, the rest of the work becomes much easier.
My unvaccinated indigenous mother of 3 young children who suffered from severe social anxiety and had to give her kids to foster care in order to stay in hospital for covid treatment brought me nothing but understanding of the depth of this dilemma. Things are never black and white.
The self compassion 5 minute break is genius. Thnx
People who refuse vaccination because “it is best for them” are making a decision that puts vulnerable people, e.g. the aged, immunocompromised or those not eligible for vaccination, at risk of serious harm. It is not hyperbole to say that people who chose to be unvaccinated have been, and continue to be, responsible for the deaths of many people.
Civility is as far as I can go dealing with the people who chose to be unvaccinated.
Thank you for emphasizing the importance of compassion to others and to self. We always need this reminder. However, as a retired intensivist and health services researcher who keeps in close touch with my burnt-out colleagues, and leads research on wellness in critical care professionals, I wonder about the limited resources we all have to demonstrate compassion. One of the big problems in health care now is compassion fatigue. See these ‘public’ articles on that topic:
https://www.latimes.com/opinion/story/2021-08-17/vaccinated-covid-doctor-shot
https://www.scientificamerican.com/article/critical-care-doctors-are-in-crisis/
https://www.theatlantic.com/ideas/archive/2021/08/health-care-workers-compassion-fatigue-vaccine-refusers/619716/
How should we prioritize our compassion? Given the demonstrated benefit of vaccination, the easy access to getting vaccinated, the harmful risks to both self and others of not getting vaccinated, and the fact that not getting vaccinated is an active choice, I am having a hard time prioritizing my compassion to the unvaccinated.
Thank you for putting these compassionate thoughts to words. I agree with the previous remarks of GB. I also have moments of frustration and disappointment when I see someone suffering the consequences of their decision and draw deeply on the ethical view of autonomy to meet the individual where they are at this moment, being aware to set aside my compassion fatigue. Politics and media are forcing judgmental views upon us and it is a challenge to avoid the vortex and stay on point. I appreciate the honest and frank remarks of previous contributors. We are all having moments of struggle. I know that I need to do self care, but struggle to find motivation. This helps. Take care.
I think this article is excellent and will strive to implement the recommendations. I do think trying to understand the motivation for refusing vaccination and remaining curious is an important step. I also agree with the statement that everyone that is just making the decision that they feel is right/best for them – I think this is just human nature. What I do struggle with, though, is the idea that someone would avoid vaccination due to a perceived unfavourable risk/benefit for them personally, while understanding that the risk/benefit ratio for others, the vulnerable, and society as a whole is favourable. This selfishness and disregard for others makes it very hard to cultivate compassion for this particular subgroup of the unvaccinated. For me it is the difference between compassion for someone injured in a crash while not wearing a seat belt vs. someone who harms others while driving drunk. The first is (relatively) easy, the second I struggle with a lot.
Our society guarantees freedom of choice in virtually all matters including healthcare. This does not remove responsibility for that freedom ie making decisions which might be harmful and dangerous to others. I cannot feel genuine compassion for folk knowingly making decisions which might harm others. Even clogging up the hospitals with unvaccinated patients is selfishly preventing those who play by the rules from accessing needed investigations and care. Unlike most responding letters urging compassion and physician “self care” I believe those who choose to be unvaccinated should be responsible in some way (maybe charged a fee for their care) rather than move to the front of the line as currently happens.
Thanks for this, it brought up a lot of thoughts for me. I try to show compassion for all my patients.
I feel like self-care / resilience has become a tyranny of its own for those of us working in health care, another way we get held individually “responsible” for situations far beyond anyone’s control. Feeling frustrated and expressing my frustrations = I’m not resilient enough, I’m not doing enough self-care. I think the truth is the system is completely broken and causes harm to people working within it. I think a normal response from someone who is being continually abused would be to express their frustrations, not just try to self-care and resiliency them away… but obviously that’s just my lack of resilience & self-care talking! Ooops.
Thank you to Dr. K for pointing out that the most common and most important causes of stress (including moral distress and burnout) in health care professionals, based on both quantitative and qualitative studies, are organizational and systemic issues, not a lack of personal resilience. Interventions ought to be directed accordingly.