Take Two Aspirin and Don't Bother Me in the Morning – what can doctors do when compassion fatigue sets in?

Charlotte Allen | Posted on 04/01/08

Grey’s Anatomy, the ABC series about surgery interns and residents that just finished a truncated fourth season due to the television writers’ strike, isn’t just a doctor show; it’s a show about doctors’ feelings. And the doctors of Grey’s Anatomy feel early and often. When a patient who can’t be saved dies during a complex lung operation, the show’s eponymous heroine, Dr. Meredith Grey (Ellen Pompeo) and her fellow surgeon-in-training, Dr. Izzie Stevens (Katherine Heigl), weep in each other’s arms. In another episode, Dr. Stevens falls in love with one of her male patients, so in love that she engineers a medical crisis for him that will move him to the top of the heart-transplant list.

And when the transplant doesn’t take and the young man dies a few days later, Dr. Stevens feels a lot about that, too — she climbs right into his hospital bed with his corpse. Jimmying medical records so as to secure preferential treatment for a patient turns out to be a gross ethical violation for fictional as well as real-life doctors, so Dr. Stevens is dismissed from the intern program, but since she’s Katherine Heigl, blonde and gorgeous, all is quickly forgiven and she’s back on the job within weeks. Dr. Stevens has to be back anyway, because she’s the new love object of her clueless fellow intern Dr. George O’Malley (T. R. Knight), who gets told by another doctor, “If you never find out how she feels, that will be your only loss.”

Patients feel (or temporarily fail to feel), too, on Grey’s Anatomy, even though their feelings often seem to play second fiddle to those of the doctors who treat them. The grieving husband of the woman who died during the lung operation declares that he can’t bond with the baby girl the couple adopted shortly before the wife’s collapse. “I don’t feel like her father,” he says. Fortunately, Dr. Stevens, who has prudently moved from cardiac surgery to the pediatric ward after the heart-transplant gaffe, talks him into more positive feelings, and there’s a happy ending for father and baby. Dr. Stevens, predictably, weeps further, indicating that she has the deepest feelings of all.

These I-feel-your-pain plot synopses might seem unbelievable to anyone who has actually been admitted to a busy, often overcrowded, real-world hospital, where the chief patient experiences seem to be interrupted sleep, high-volume conversations, ringing cell phones, and endless rounds of visits to the bedside by physicians, nurses, phlebotomists, and orderlies — everything but the high-level hand-holding that is a weekly staple on Grey’s Anatomy. Writing in the New York Times last August about her tumultuous overnight hospitalization for pneumonia, author Caitlin Kelly commented, “[T]he next time I really need a rest, I’m going to try to stay home.”

In fact, Grey’s Anatomy seems to be trying to deal, in its own overblown, oversexed, Hollywood-ish way, with a very real phenomenon among twenty-first-century doctors and other medical professionals that goes by the name of “compassion fatigue.” It’s a version of burnout in which physicians come to feel that they have nothing more to give. They are confronted with a combination of insurance and managed care–driven time constraints, government and regulatory association–required mountains of paperwork, hyper-specialization that prevents physicians from treating their patients as whole persons, and the subtle pressures of the “patients’ rights” movement that demands that patients not only be competently treated but be happy about it as consumers. “They [doctors] increasingly feel like they’ve lost control of medicine,” says Dr. Edwin Leap, a newspaper columnist, blogger, and emergency-room physician in rural Seneca, South Carolina.

The typical response to compassion fatigue, epitomized in an April 2000 article in Family Practice Management, a journal of the American Academy of Family Physicians, is to advise doctors to take a little time off, meditate, and “recharge your batteries daily” via exercise, a healthy diet, and meaningful conversations with loved ones. That is, physicians should use physical and mental strategies to get themselves into the mood to empathize more deeply with patients. That’s the message of Grey’s Anatomy too: that the way doctors feel about their patients or other people is paramount. The problem is, feelings are ultimately transient. What doctors instead may really need — and what seems to be sorely lacking in contemporary discussions of fatigue and burnout — isn’t so much subjective feelings of compassion as an objective ethos of compassion to help them transcend the day-to-day pressures of exhaustion and stress.

“It’s a matter of emotion versus ethos,” says Wesley J. Smith, author of The Culture of Death: The Assault on Medical Ethics in America. “We want our doctors to care, but we assume that if something feels good to me, it’s the right thing to do.” In Smith’s view this confusion between doctors’ feelings and their obligations leads many of them to project their own feelings onto their patients — to assume, for example, that an extremely sick, elderly, or mentally disabled patient would prefer to be dead. “We want to get rid of suffering by getting rid of the sufferer.”

There is no doubt that compassion — the word derives from the Latin verb compatior, meaning “suffer with” — is an indispensable component of medical treatment that is good for patients and good for doctors. In his bestselling 1996 book, The Rise of Christianity, sociologist Rodney Stark wrote that part of the reason the Christian religion grew so rapidly during its early years was Christians’ belief, derived from Jewish ethical teaching, that they had a duty to minister to the sick, even at the risk of their own lives. That gave Christians a demographic edge over their pagan neighbors during a time when poor sanitation and ignorance about germs meant that deadly epidemics regularly decimated urban populations. Modern medical experts believe that simple nursing of the sick — providing nourishment and clean, comfortable beds — can reduce mortality during a plague by as much as two-thirds, even when the nurse is unable to provide any effective medical treatment. Thus in ancient times proportionately more Christians than pagans tended to survive outbreaks of contagious disease. “In the case of bubonic plague, just making sure that they had water and some food made a difference in terms of survival, and it took a certain kind of person to do that,” says Stark, now a professor at Baylor University.

Even nowadays, a few kind words from an oncologist can help a cancer sufferer get through grueling rounds of chemotherapy, and nurses report how much better even their sickest patients can feel just having their pillows fluffed or their hair washed. Conversely, when hospital systems break down, as seems to be the case with much of Britain’s socialized National Health Service, it is exactly in this area of basic comfort care that the worst, most demoralizing tolls on patients seem to be exacted: lack of privacy, shortages of blankets and pillows, diseases spread by rampant filth, nurses who consider it beneath them to handle bedpans, change sheets, or spoon-feed the helpless.

American medical care has not yet sunk to NHS-level chaos for patients, but compassion fatigue among physicians is real enough, indicating that something has gone awry with the psychic and moral foundation they receive that might help them cope with the stresses of modern-day medicine. From ancient times until very recently, the basic ethical code for physicians in the West was the Hippocratic Oath (see sidebar). The oath does not mention the word compassion, or even anything like it, but it does state clearly that doctors must always act “for the benefit” of their patients and “keep them from harm and injustice.” That language, requiring physicians to put their patients’ interests ahead of their own, demanded that they perform acts that would outwardly be defined as supremely compassionate — protecting them from harm — but did not demand that they always feel like it. This was a high standard of selflessness, but at the same time it allowed physicians to detach themselves and how they might personally feel about particular patients from the ethical duties that they owed them.

It is a standard that might be particularly valuable for guiding doctors nowadays, when increasing numbers of their patients aren’t handsome young men or tragically dying young mothers, as on Grey’s Anatomy, but cranky, demanding, physically unappealing, and in many cases demented elderly people toward whom it is easy to become callous. “The obligation of the doctor under the Hippocratic Oath is to serve the patient,” says Dr. Leon Kass, a physician who teaches at the University of Chicago and who served as chairman of the President’s Council on Bioethics from 2002 to 2005. “The physician is the patient’s guardian, and the strength or lack thereof of the physician’s feelings is irrelevant.”

Furthermore, says Leap, the South Carolina emergency-room physician, many young people going into medicine nowadays have never had a religious framework that might reinforce the Hippocratic Oath’s obligations. In the old days, Leap explains, “when doctors took the Hippocratic Oath, they probably didn’t care about what Hippocrates said, but they did care about what Jesus said. Nowadays they’re not taught absolute values. Without a framework of that kind, they believe that their medical career defines them and is supposed to give them joy. And when that doesn’t happen, they can feel a lot of anger. For a lot of doctors, with the paperwork and the regulation, the practice of medicine starts to look very mechanistic, less a calling than just a job. At my rural hospital we’re often overwhelmed and understaffed — we don’t have enough nurses. When you mix that in with the customer-service model that means we’ve got to make our patients happy, and the fifteen more patients per doctor and the three less nurses and the fact that we can’t turn away patients, well — American physicians take a lot of pride in what they do, and we want so much that we often have false expectations. Fortunately, we all share the same ethical framework here in my hospital. This is the buckle of the Bible Belt, after all.”

Allen Roberts, an emergency-room doctor in Fort Worth, Texas, who writes the Grunt Doc blog (he served as a Marine Corps physician during a stint in the Navy), is not overtly religious, but he believes that pride in one’s professionalism is the key to treating patients selflessly while avoiding burnout.

“Do doctors care less about their patients nowadays?” Roberts asks. “I entered medical school in 1989, and I graduated in 1993, and I don’t think that’s the case. I’m constantly impressed at how thorough 99 percent of my colleagues are with their patients. They’re not getting reimbursed for that. Yeah, it can sometimes be very painful. You’ve got your classic drug-seeking patients who come in here, and they’re bitching because you won’t give them drugs, but there’s no excuse for letting your patients know how you feel about them. So, yeah, there’s a compassion fatigue that sets in after about six months. You’ve got to stand back and say, ‘Your pain is real, but it’s not my pain.’”

Professional pride, religious faith, perhaps a revival of the ethos of detached service behind the traditional Hippocratic Oath — those are all foundations for extending genuine, morally grounded compassion to patients that is not dependent on the physician’s personal feelings à la Grey’s Anatomy. Patients will benefit, and so, inevitably, will doctors, in the knowledge that their calling is predicated on ethical obligations that transcend particular circumstances. “I sometimes speak at medical schools,” says Wesley Smith. “A lot of the young people there are quite idealistic, and I try to reach them, to reach people who are just going into the profession. We shouldn’t write off these young doctors and nurses at all.”


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Want To Solve the Burnout Problem? Maybe We Should Bring Back Asclepius

At the core of the notion that doctors owe their patients a duty of compassion is the Hippocratic Oath, currently administered in some form or other to graduating students at nearly all U.S. medical schools. The oath is traditionally attributed to — although perhaps not written by — Hippocrates (c. 460 B.C.–c. 380 B.C.), the Greek physician known as the “father of medicine” because he and his disciples turned the practice of medicine, which had hitherto been regarded as a branch of sorcery, into a genuine profession, with its own code of practices and ethics.

The Hippocratic Oath was revered by physicians throughout the ancient world. When medicine went into decline in the West after the fall of Rome, Islamic medical practitioners preserved the oath along with other writings attributed to Hippocrates, passing them on in turn to Jewish and Christian physicians (the twelfth-century Jewish physician-philosopher Moses Maimonides composed an adaptation of Hippocrates’ oath). As medical education became formalized in nineteenth-century America, the swearing of the Hippocratic Oath became a standard ritual at graduation.

According to the 1950 translation by J. Chadwick and M. N. Mann, the new doctor would “swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant.” The covenant included treating one’s medical mentor the same as one’s parents (supplying money if necessary), keeping the sick from “harm and injustice,” never giving a deadly drug, even if a patient requested it, and never suggesting such a drug. “In purity and holiness I will guard my life and my art,” doctors vowed. The anthropologist Margaret Mead wrote: “For the first time in our tradition there was a complete separation between killing and curing.”

To modern ears, the oath’s invocation of Greek gods no longer worshipped, such as Apollo and Asclepius (Apollo’s son in classical mythology), can sound pointlessly ritualistic. But the names of those gods served an important symbolic purpose in reminding physicians that their calling was not just the use of their training to make money but had an aspect of sacred duty: “purity and holiness.”

The Hippocratic Oath imposed an objective standard of compassion upon physicians that did not depend upon their personal feelings about particular patients. The oath simply stated — twice, in fact — that physicians were to ply their trade “for the benefit of the sick” and that they were to keep their patients “from harm and injustice.” Leon Kass, former chairman of the President’s Council on Bioethics and a professor at the University of Chicago, explains: “This commands our attention as physicians not because the sick have rights or because they play upon our heartstrings, but because we are healers.”

During recent decades, however, the traditional version of the Hippocratic Oath has fallen into disuse in medical schools partly because portions of it are obsolete, practically speaking (few doctors nowadays are called upon to support their aging teachers), and partly because, with regard to such issues as physician-assisted suicide, many doctors now believe that killing can be a legitimate form of curing, or at least of alleviating misery — something that would have shocked their predecessors. So most medical school graduates nowadays either write their own oaths or use a version of an updated oath composed in 1964 by Louis Lasagna, a dean at Tufts University’s medical school. Needless to say, Asclepius is gone, and on first reading, this contemporary oath may actually come across as more compassionate than the ancient one.

Among the ethical standards a newly minted physician promises to uphold, he will apply all measures called for, “avoiding the twin traps of over-treatment and therapeutic nihilism,” and the young doctor will “remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.” The physician blithley notes that it may also “be within my power to take a life” and that this is an “awesome responsibility” that must be faced with “awareness of my own frailty.”

This is an oath for the world of Grey’s Anatomy. It relies for moral force on the language of feeling and emotion, upon the “heartstrings” that, as Leon Kass points out, the traditional Hippocratic Oath avoided. Besides “warmth, sympathy, and understanding,” the new oath invokes the “joy of healing” and the physician’s capacity to “enjoy life and art.” The practitioner’s own feelings become paramount. This might not be an oath that is going to be of much use when compassion fatigue sets in, as it will, even for the most dedicated physicians. Couldn’t our young doctors benefit from bringing back Asclepius, more astringent, to be sure, but ultimately more compassionate?


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Compassion Isn’t for Sissies: Hospice and L’Arche

Compassion in medicine often consists of the simplest of gestures that reassure the sick and the disabled that they remain valuable and are not beyond the love of the healthy and the non-disabled. Two examples, both dating perhaps coincidentally to the mid-1960s, are the hospice movement of comfort care for the dying and L’Arche, a network of religiously based communal houses in which mentally disabled people and their caregivers live together and share lives.

Cicely Saunders, a nurse and medical social worker during the 1940s, founded the modern hospice movement. It grew out of a kind of love story with its roots in the horrors of World War II. Working in a London hospital, Saunders met David Tasma, a Pole who had escaped from the Warsaw ghetto and fled to Britain during the war, only to find himself dying of cancer in excruciating pain on her ward a few years later. Although Tasma’s English was poor, the two talked and talked. She helped him make his peace with God, and when he was gone, she resolved to find a better way for the dying to spend their last days, as comfortable and free from pain as possible and surrounded by care and love. So was born the modern hospice movement.

After Tasma’s death, Saunders trained as a physician, and she used her pharmacological studies in medical school to pioneer the notion that the dying deserved to receive as much in the way of painkilling drugs — “palliative care,” in Saunders’s words — as they needed, even morphine and other opiates that many doctors had used only sparingly for fear of creating addictions. Hospice care for the dying had existed in limited form for centuries, mostly in institutions operated by Catholic nuns, but the nuns were typically not medically trained and knew little about pain management. In hospitals, physicians tended to give up on the dying, whose cases they regarded as beyond their powers of healing — or they employed repeated burdensome interventions to extend the lives of dying patients by a few days. They also tended to ignore pain control, which was not even taught at most medical schools, and when they did administer injections, it was often too little too late.

Saunders believed that people in the last stages of terminal illness needed places to die in peace and comfort, where the main medical aim would be not to take drastic steps to prolong life but to alleviate pain or reduce it to a minimum by the controlled administration of drugs so that patients remained alert until the end. The 1960s marked the growth of the euthanasia movement, and many argued that suicide should be an acceptable solution to the problem of chronic, intractable suffering. Saunders, a fervent evangelical Christian, was adamantly opposed to euthanasia, and she proposed hospice, palliative care, and diligent nursing as the more loving way to allow the terminally ill to die with dignity. She also argued that a peaceful natural death in a pleasant facility, not a busy hospital ward, helped both the dying person and survivors to come to terms with the inevitable mentally and spiritually.

It took years of prolific writing and lecturing for Saunders to convince a reluctant and sometimes hostile medical establishment of the value of her approach to dying, but in 1967 she finally opened the first modern hospice in Britain, St. Christopher’s Hospice in London. St. Christopher’s featured cheerful, airy wards where family members, children, and even pets were welcome. By 1993 there were 173 hospices in Britain that hewed to Saunders’s philosophy of dying and around 2,000 in the United States. For her tireless work, she was made a Dame of the British Empire in 1980 and inducted into the Order of Merit in 1989. In 1981, Saunders was awarded the Templeton Prize for Progress in Religion. She died in 2005 at age ninety at her own St. Christopher’s Hospice.

Annette Johnson was a volunteer for several years at a hospice in the Houston area, where she would often simply sit with patients, whether in their own homes or in nursing homes, freeing family members to perform errands. Or she used her nursing skills, for example, to help a family care for a fourteen-year-old boy in a coma. Johnson particularly remembers having “delightful conversations” with a man who was dying of cancer. “There were times the families would tell me things they couldn’t tell other family members because they couldn’t let on how hard it was to go through what they were going through,” Johnson recalls. But even in the hospice environment, the volunteer may face moral dilemmas — Johnson did and ultimately resigned. She felt that sometimes drugs were used to bring on death more quickly. “This is where I have an ethical problem. Is this compassion, and if so, for whom — the patient or the caregivers?” Johnson asked.

L’Arche began in France in 1964, when Jean Vanier, a layman, and Father Thomas Philippe, a Dominican priest, invited two men with mental disabilities to share a house with them in the village of Trosly-Breuil in Normandy. The men had been living in an institution and neither Vanier nor Father Philippe had any training in caring for the disabled, but they believed they would thrive in a loving homelike setting (the word “l’arche” is French for “ark,” calling to mind Noah’s shelter against the flood). Today there are more than 120 L’Arche communities in thirty countries around the world. Although their roots are the Gospel mandate to care for the weak and the sick, L’Arche communities welcome participation by members of all faiths.

A recent weeknight dinner at a twenty-five-year-old L’Arche community in the heart of Washington, D.C., typifies the ways in which the disabled and their caretakers find themselves helping each other. There, six “core members” (as the disabled are called) ages seventy-eight and on down, and five assistants share a clean but shabby house that looks as though it was furnished at a rummage sale. Paper hearts left over from Valentine’s Day are strung across the living-room ceiling, and the walls are decorated with artwork by the sister of Antonio and Raul (their names and those of other L’Arche core members have been changed), two Cuban-born core members.

“Much of the care we give and receive here is very simple,” explains one of the assistants, Matt Rhodes, who has deferred entry into Princeton University’s seminary to spend time living and working at L’Arche. “We care for other people’s bodies. We wake up the core members in the morning, help them shower, brush their teeth, and dress.” The assistants also take core members to doctors’ appointments and keep track of their medical information.

Assistants, who, like the core members, go through a period of discernment before they are allowed to join the community, say the crux of life in L’Arche is relationships. “We don’t detach from them, and they don’t detach from each other,” says Caroline Fischer, an assistant and a recent Vassar graduate.

Take Stella, a fifty-nine-year-old black woman who became severely disabled after going through a car windshield at eighteen months old. Immaculately turned out in old clothes and able to make friends when she helps cleaning up at a nearby church coffee house, Stella loves to dance and to talk about forgiving and helping people at nightly prayer time — “saying the Beatitudes,” as Rhodes describes it.

Dinner is a simple meal at an oak table in the kitchen, with Antonio in his wheelchair, Raul talking nonstop mostly in Spanish, and Brother Jerome, a young Dominican who is a frequent L’Arche guest. After dinner a candle is lit and an assistant reads a reflection on a passage from Matthew’s Gospel. Then come the prayers. Antonio can’t read his Bible but pretends to, and he prays for an assistant’s mother with Lou Gehrig’s disease. Dave, the oldest core member, wants to pray for his brother. Richard, another core member, who wears a hearing aid and remembers that Ronald Reagan was president when he came to L’Arche, begins, “Our father .... ” The candles are blown out.

“Everyone can be different but equally loved,” says Matt Rhodes. That is the very meaning of compassion.