Expert Shares Insights on Compassion Fatigue and Physician Burnout
There are 3 components of burnout: exhaustion, depersonalization, and a sense of lack of efficacy.
The term “compassion fatigue” was originally coined by Joinson,1 a nurse researching burnout in the emergency department. It is now understood to affect workers across the spectrum of helping professions, and to be extremely prevalent among physicians.
To shed light on this common and debilitating condition, MPR interviewed Dike Drummond, MD, Executive Coach and CEO of The Happy MD, an organization focused on physician burnout prevention and leadership.
How does compassion fatigue develop?
Many circumstances converge to create the phenomenon referred to as “compassion fatigue.” These include the actual demands of the job, the incessant exposure to pain and suffering, the sense of responsibility for the health and lives of others, and the high volume, high stress working environment in many healthcare organizations. However, I think it is important to note that “compassion fatigue” is part of a larger picture and cannot be looked at in isolation.
What is the larger context in which compassion fatigue develops and plays out?
Compassion fatigue cannot be taken out of the larger context of burnout. In fact, it is the second symptom of burnout. According to the Maslach Burnout Inventory,2,3 which is the gold standard for measuring burnout, there are 3 components of burnout. The first is physical exhaustion. The physician wonders, “How much longer can I keep going like this?” The second is depersonalization. Physicians find themselves becoming cynical and sarcastic toward patients. The third is a sense of lack of efficacy. “What's the use? My work is no longer serving any purpose.”
Do you think that compassion fatigue is becoming more prevalent or getting worse?
Burnout and compassion fatigue are not new. Constant exposure to suffering and pain has always taken a toll upon people dedicated to relieving suffering and pain.
But certain aspects of burnout have worsened in recent decades.
The EMR is a major cause of stress that did not exist 20 or 30 years ago. EMRs were not designed by doctors and the user interface is brutal. One recent study showed that, on average, physicians spend two hours documenting for every hour spent in patient face-to-face contact.4 Back in the days of paper charts, no one ever spent that much time documenting. You either wrote notes by hand or you dictated them. And the advent of patient portals, e-mails, and texts means a large number of additional steps of dealing with patients during the course of the day. We returned patient calls back in the day, but didn't have to deal with EMR, email, text and patient portals like today's physicians do.
What other factors increase burnout in physicians?
Diagnosis and treatment modalities are progressing rapidly and the rate of change itself is increasing over time. This is a good thing for patients, but it has serious consequences for doctors. The impact on physicians can be overwhelming when combined with patient care related stresses. Annually, there are new clinical guidelines, new diagnostic techniques, and new therapeutic regimens. It is hard to keep current with a profession that gets more complex over time.
Patients also come in to their visits with more information and opinions, often taken from the Internet. Physicians have to dispel misinformation or to justify their therapeutic decisions. It is harder to feel empathy for self-righteous or argumentative patients.
How does the current healthcare environment contribute to burnout in general and compassion fatigue in particular?
Many, if not most physicians have gone from being in control of their practices perhaps with a few partners, to being employees of large organizations that shift and change as hospitals and health systems engage in mergers and acquisitions. As employees, they have little input in when and how they see patients, and little autonomy. Being an employee in any industry is challenging and can lead to burnout when there is bad leadership or a difficult boss. But physicians have gone from being the boss to having a boss. That is a difficult transition for doctors. These pools of 100 to 200 to 300 employed physicians in a single organization are a new phenomenon as well. We are only just beginning to learn how to lead a group of physicians of that size.
Can physicians recover from burnout?
Physicians absolutely can and do recover from burnout. Many assume that they will have to quit their positions or even leave the practice of medicine, but in my experience, 70% will recover without changing jobs, and most will never need to leave the practice of medicine.
How do you approach burnout and compassion fatigue in your clients?
I frame burnout as the depletion of three “energetic bank accounts.” It is similar to your actual bank account except these accounts hold your life energy. It's like “the Force” in Star Wars. You have to make regular deposits in your money account at the bank if you want to make withdrawals. Similarly, if you take out more energy than you put in, you drain your account and eventually end up with a negative energy balance. Burnout happens when you continue to see patients when your energy account balances are below zero.
There are three “energetic accounts,” which correspond to the three symptoms of burnout: physical, emotional, and spiritual.
When you deplete your physical “energy account,” you are expending more physical energy than you are replenishing. This goes back to residency, when we are trained to continue coming to work, even when our energy is below zero. Doctors are taught to neglect their own health, and eventually that starts to catch up. Draining the physical “energy account” corresponds to the exhaustion stage of burnout.
The second “energy account” is emotional. A negative balance here gives rise to the second stage of burnout, which is depersonalization. Physical exhaustion can lead to impatience with patients and the desire to get through the visit so that the myriad other tasks can be fulfilled and you can go home. So the physician experiences an emotional shutdown that makes it harder to feel empathy for the pain and suffering of patients.
Both of these contribute to the third stage of burnout, which is lack of efficacy—in other words, depleting the spiritual “energy account.” You begin to question the meaning of what you are doing in a profession you entered because the vision of alleviating suffering was so meaningful to you.
How can these three “accounts” be replenished?
It is essential to learn how to lower stress at work and increase your ability to recharge at home. Small changes on both sides of that equation can make a big difference and allow the doctor to always have a positive energy balance.
We teach 235 tools to prevent or overcome burnout, and it is reassuring to know that there is such a large smorgasbord to choose from. Most doctors employ a burnout prevention strategy that uses just 3 to 5 of these tools.
What are some of the main strategies you recommend?
Almost everyone has a weekly work calendar. I suggest that you also create a weekly “life calendar” and keep it on your cell phone together with your work calendar. Include in your “life calendar” those things you would like to create a work-life balance.
If you are unable to find anything to do because work is taking up all of your time, this is the first clue that something needs to be changed on the work front so that you can begin to include non-work activities in your life. One way to adjust your workload is to template “broken record moments” in documentation. If you find yourself feeling like a broken record, writing the same note over and over again, that is a huge opportunity to create a template. With a template, that same note becomes a single keystroke. When you have templated all your broken record moments, you will get home sooner without having to work harder. Guaranteed.
Some physicians will indeed need to change jobs, if their current position is untenable. If this is the case, I advise the doctor take some time to build a written Ideal Job Description and use it to focus your search. This will make sure that you are focused on finding a better situation instead of simply running away from a bad one. We offer specific online training in how to build your Ideal Job Description and engage in the job search and interview process.
Is their anything physicians can do on a day-to-day basis to combat burnout?
I recommend some type of “boundary ritual” at the end of the workday. This is akin to pushing the “off” switch on the always-running “doctor programming.” Your boundary ritual is anything you do at the boundary between work and home while telling yourself, “With this action, I am coming all the way home.” For some people, it might be walking the dog, taking a shower, having a cup of tea, or simply taking a deep breath when you turn the doorknob of your home. This makes a clear internal state shift that you are no longer at work and in doctor mode.
Incorporating other types of self-care, such as yoga, running, or meditating, is very important to lower stress and facilitate recharge.
Spending time with loved ones is an essential way of replenishing your emotional energy account. Imagine that all the people you love are standing in front of you. How many have you been in touch with lately? Your job is to connect in the next week with one of them—through email, calling to say hello, or having a cup of coffee. Make this a regular practice. When you feel you are spending an adequate amount of time with those you love, you will have more emotional energy for your patients. And make sure you focus on the loved ones you live with, like your wife and children. If you're distracted by work, you don't have the bandwidth to spend quality time with them, and you will more easily feel compassion fatigue.
Do you recommend specific techniques or exercises to address compassion fatigue?
In my experience, empathy exercises are counterproductive. Doctors who are burned out and trying to take on additional activities to bolster compassion and empathy find that these exercises add to their stress and burnout and quickly make everything worse. This is why you cannot consider compassion fatigue in isolation. The key is to realize that it is just one symptom of the underlying burnout. When we focus on preventing burnout to maintain adequate levels of physical, emotional, and spiritual energy, the doctor will naturally and automatically have plenty of empathy and compassion available.
- Joinson C. Coping with compassion fatigue. Nursing.1992 Apr;22(4):116,118-9,120.
- Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422.
- Maslach C, Jackson SE. MBI: Human Services Survey for Medical Personnel. Available at: http://www.mindgarden.com/315-mbi-human-services-survey-medical-personnel. Accessed: January 1, 2018.
- Sinsky C, Colligan L, Li L, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med. 2016 Dec 6;165(11):753-760.