Do you care too much?

As a care-giving professional you're a candidate for compassion fatigue. Here's how to recognize it and steps to take to overcome it.

By Gail Garfinkel Weiss
Senior Editor

From his med school graduation in 1987 until the day he began an extended sabbatical in 2002, pediatrician Lawrence Palevsky maintained a work schedule that would have put the Energizer Bunny to shame: After the typical grueling residency and fellowship, his first job was a four-year stint in a pediatric emergency room during which time he took call for a private practice on weekends. Over the next five years he was head of a pediatric intensive care unit and worked as an outpatient physician.

Then he went into private practice at the Continuum Center for Health and Healing, affiliated with New York City's Beth Israel Hospital. "I was the only pediatrician doing a primary care practice plus a consultation practice for holistic and alternative medicine," he says. "There were times I felt I was working harder than when I was a resident. I believed that much of my success was due to my tremendous involvement in my work. I never got a break, even when my father died [during his residency]. I just kept going."

But 16 years on the treadmill had taken their toll. "No matter how much I slept I was still tired," Palevsky says. "I was increasingly grumpy. There were times toward the end when I just couldn't listen to my patients in the way that I needed to. The idea of a holistic practice is not to wait for something critical to occur, but to look at the factors contributing to the symptoms. I realized that if I was going to ask families to reassess the way they lived their lives, I had to do that myself. So, in October I closed my practice and moved from New York to Reston, VA."

Giving until there's nothing left to give

Palevsky was suffering from compassion fatigue, a form of burnout commonly associated with people who dispense care, such as nurses, hospice workers, grief counselors, and, of course, physicians. Unlike garden variety fatigue, which is a common result of overwork, compassion fatigue results from caring to the point that you're drained of empathy.

What causes it? "Unrealistic expectations: Thinking that to be the ideal physician you need to give endlessly of yourself, cure everybody, always be right, and never make mistakes," says David Posen, a family physician who is now a stress management consultant in Ontario, Canada. "If every setback means that you have to try harder be more vigilant, double- and triple-check everything it won't be long before you're running on empty.

"Doctors are self-selected for compassion fatigue because we want to help people," says Posen, the author of Always Change a Losing Game (Key Porter Books, 1994) and Staying Afloat when the Water Gets Rough (Key Porter Books, 1998). "But we all have setbacks. People will die despite our best efforts. Sometimes it's hard to keep that in perspective."

"People with compassion fatigue feel vulnerable all the time," adds John-Henry Pfifferling, a medical anthropologist and director of the Durham, NC-based Center for Professional Well-Being, which specializes in physician stress management. "They've lost their sense of hopefulness. Their patients' deaths affect them very deeply. They've given so much there's nothing left to give."

In his monograph on the subject, Pfifferling writes of physicians who feel "used up at the end of each workday" or "plucked bare." He writes about one doctor who acknowledged, "I found myself praying that the ambulance coming to my emergency department would bring only DOAs."

"You might be short-tempered with your family, friends, colleagues, and patients," says internist Lee Lipsenthal, founder of Heal Thyself Programs in San Anselmo, CA. "Men with this syndrome tend to withdraw socially; they avoid conversation and crave a lot of quiet time. Both sexes rely more on stimulants to keep going."

Recognizing the problem and getting help

"You are generally the last person to know that you're suffering from compassion fatigue," says Lipsenthal. "Your spouse, kids, friends, and colleagues will probably notice the problem before you do." Lipsenthal cites a case in point: "When a friend of mine told patients he was canceling a vacation, two of them replied, on the same day, 'Doc, you need a vacation.'

"If a physician essentially has no life outside the office, that's a predictor," says Lipsenthal. "Patient turnover is also a predictor, as is patient satisfaction. Generally speaking, if the physician isn't satisfied, patients aren't satisfied."

An alert practice administrator, Posen says, should keep an eye on physicians who think of themselves as being their job. For these people, "'Doctor' is not what they do, it's who they are," he notes. "They can't distinguish a professional disappointment from a valuation of their own personal worthiness."

If you feel yourself sliding down that slippery slope toward compassion fatigue or if someone indicates that you're unusually irritable or that you've lost your sense of humor, it's time to take corrective action. Elizabeth Pector, an FP in Naperville, IL, says that during tough times "it helps to admit my lack of bubbly enthusiasm to patients. I've been fortunate not to hit rock bottom in terms of burnout because I know when to take a deep breath, admit my humanity, and slowly get back in order again."

In addition to putting on the brakes, here's what the experts recommend:

Evaluate why you're feeling spent. "Is it the amount of time you're putting in?" Lipsenthal asks. "Is it because you're unable to say No? Is it because you're not getting enough relaxation time? Is it because you've lost contact with the fun of medicine?"

Do something different. "To recapture the joy of medicine you need to work differently, not more," says Lipsenthal. You can see 20 patients in the same number of hours you once saw 40 patients and have more fun. Yes, your income will decrease, and that's a tradeoff decision you'll have to make."

Take some time off. "We're big fans of sabbaticals," says Pfifferling of the Center for Professional Well-Being. "Sometimes a little break will help; other times a longer hiatus is needed." In David Posen's view, "Taking time off is not just to get your energy back, it's to gain perspective. Acknowledging the need for time off doesn't mean that you're weak or inadequate. It just means you're human."

Seek help and support. This can be individual psychotherapy, marriage counseling, a support group, a class in stress management, or counseling with a religious leader. A counselor can help you establish realistic expectations and perspective. "You need to understand that you're not going to have one success after another. Even you can get tired. Even you can make mistakes," says Posen. "At the same time, you have to see yourself as being more than your job. It may be the most important part of who you are, but it's still only one aspect."

Do what you tell your patients to do. "Don't forget the importance of diet and exercise. The more physically fit you are the better you'll sleep and the more energized you'll be," says Pfifferling.

Make sure you're getting enough time with family and friends. "People who are isolated are more at risk," says Posen. "If you're having difficulties, friends and relatives can listen to you, give you moral support, and confirm that you're loved and appreciated."

Get in touch with your spiritual side. "Physicians who have religion in their lives are happier in general. It helps you understand what's important and what's not," says Lipsenthal.

Take up a hobby or take a class. "Creative outlets are rejuvenating," says Pector. "Playing or listening to music and building spiritually oriented Web sites are therapeutic for me. I learned some intriguing things about deaf culture when I took a sign language class." Posen agrees that pursuing other interests "gets a physician away from work, and from thinking about work."

Write a journal article. Yes, that might sound like more work, "but it's a different kind of work," says Lipsenthal, "and it might help you reconnect with the science and fun of medicine."

Meditate. "Meditation gives you perspective and helps you focus compassion and empathy," says Lipsenthal. "It leaves you in a better emotional place than driving your BMW bitching, moaning, and whining." (For more on meditation, see "Stressed out? Try this" in this issue.)

Pector has other "heal thyself" remedies: "Lower your expectations of yourself and others around you to levels that are achievable. Celebrate small accomplishments. Minimize your exposure to things you can't control. Say No to impossible demands. In particular, look at the tasks you find to be joyless, pointless drudgery. Is there a way to eliminate them, delegate them, or make them briefer and more palatable?"

Burnout + seeing patients can = trouble

If you're suffering from the physical and mental exhaustion that's characteristic of compassion fatigue, you're not likely to be at the top of your game in the office.

Not only are burned-out doctors more apt to make mistakes, says Lipsenthal, they're lawsuits waiting to happen. "Lawsuits have a lot to do with relationships," he notes. "A doctor who is empathetic and caring is less likely to get sued than one who's dissociated."

So, give yourself permission to step back. "Physicians who work 70 to 80 hours a week are looking for trouble," says David Posen. "Even if someone's working 60 hours a week on a regular basis, I'd like to know why."

Recharging your emotional batteries might require hanging up your stethoscope for a time. Pediatrician Lawrence Palevsky is now writing and doing some public speaking.

FP Elizabeth Pector, on the other hand, refocused herself by opening her own practice. "Envisioning a better reality," Pector says, "is the first step toward getting there."

Want to know more?

The Doctors' Page www.doctorspage.net, a Web site for practicing physicians, has a "Life in Practice" section that focuses on physician health, satisfaction, stress, and well-being.

On his Web site, www.davidposen.com, stress management consultant David Posen has more than 50 columns he's written on stress and lifestyle management.

The Web site for the Center for Professional Well-Being, www.cpwb.org, features a burnout risk appraisal. "Burnout: Effectively Managing a Grief Syndrome," written by CPWB director John-Henry Pfifferling, can be ordered by sending $10 to the Center for Professional Well-Being, 21 West Colony Place, Suite 150, Durham, NC 27705. The Center's phone number is 919-489-9167.

For information on health-related lectures, workshops, and retreats for health professionals conducted by internist Lee Lipsenthal, founder of Heal Thyself Programs in San Anselmo, CA, go to www.healthyselfprograms.com, or call 800-769-0638.

FP Elizabeth Pector's Web site, www.synspectrum.com/healself.html, has numerous articles, including "Overview of compassion fatigue," as well as lists of readings on the subject and links to other sites.

Gail Weiss. Do you care too much?

Medical Economics

May 23, 2003;80:64.