I understand. I’ve been there. 6th shift in a row, department is overcrowded, patients are upset, consultants are being rude, you’re cognitive and emotionally fatigued – it becomes easy for empathy and compassion to fade. The problem is that because of overwhelming system flaws – empathy and compassion fatigue are widely prevalent amongst all healthcare providers, and inevitably it becomes patients that suffer the most. Unfortunately, this is where we sit now – where an entire system suffers from compassion and empathy fatigue, so we’re at a precarious crossroads.
I had a rather unusual interaction the other day, where a consultant advised me that I should not let a family member of a patient go home in the middle of the night, because the “admitting service” would need to use them for collateral. At 3 am. I obtained all the collateral information from this family member – they didn’t really have anything to add. He did, however, have children who were going to wake him up in a few hours, and his family member had to be admitted to hospital. Keeping that family member in the ED all night to maybe provide collateral when the consulting service shows up seems unnecessary, and outside the principles of patient-centred care.
This interaction highlights a growing area of concern for me – that as hospitals become increasingly overcrowded, and healthcare professionals becoming increasingly more burned out, we are observing a concerning lack of empathy for the patients and families that we treat. Dogma is often left standing in the way of rationale and compassionate care.
Where did the Empathy go?
It is through no fault of any individual, but a product of the system that we are working in. Historically, healthcare providers focused on communication with patients, developing rapport and expressing empathy. Increasing complexity and demand has instead shifted the focus to Electronic Health Record systems, documentation, and an ever increasing list of patients and cognitive demands. Medicine has become increasingly technical, drawing our attention away from the patient.
Physicians are managing busy teams and services, and the culture of medicine is one that encourages putting up brick walls and turfing patients (transferring a patient to someone else’s care for reasons that are not strictly medical). With overcrowding becoming increasingly more prevalent, everyone is trying to minimize their cognitive load – and while this is engrained in medical training, and an inevitable consequence of overcrowding, the person who suffers the most in this approach is the patient.
It is the patient that is the one most often forgotten in a struggling system. Delayed C-Collar removal, procedures, admissions, consultations and political turf wars all harm patients, and truly represents a lack of empathy to the patient and their lived experience.
This is not to say that hospital structures, hierarchy, overcrowding, flow pressures, or a sicker patient population are conducive to breeding patient empathy, but we have to remember that it is not the patient’s fault. The patient and the family are appropriately ignorant to the pressures of the healthcare system; what is important to them is that they are sick in that moment. It is so easy in medicine to stray from that concept of ‘patient centred care’ when there are so many competing external pressures.
Empathy, roll it back
This is why frontline providers in the Emergency Department, and educators within our healthcare system, that we provide these reminders and opportunities to identify patient centred care and empathy for those in front of us.
When I graduated residency, I had the opportunity to take some time off (highly recommended if you are able) and as I reflected on my final year of residency, somewhere on a beach, I had an epiphany and recognized that I had been suffering from burnout. I had always had the perspective that burnout was personality based, and due to a lack of resiliency. I also, erroneously, thought that concepts of wellness were a bit bogus (I was wrong… I have grown). But the biggest flag in my mind was the recognition that in my final year of residency, my empathy towards patients was lacking. This was an important lesson for me to learn, perhaps the last one of my training, because it instilled within me the recognition that I had an inaccurate perspective on medicine and my role in the system.
We all experience this to some extent; 6th shift in a row? Compassion fatigue is a serious problem. I remember as a medical student, a staff telling me that he could only work 3-4 shifts in a row before his clinical performance suffered – and I remember being surprised at the time, and thinking that was ‘soft’. I was wrong about that as well (growth is humbling), and have come to see that this is a very real problem that many of us struggle with.
The conceptualization that doctors are too busy for empathy is hardly a new one. Studied previously, our system pressures often create the perception that empathetic moments are difficult because they slow us down and distract from the task(s) at hand.
Even when we do empathize with our patients, it is often because of variables that we are unable to control – patient is stuck in a hallway for hours on end, because no beds are available. Delayed surgeries, procedures etc – and this creates an overwhelming sense of morale distress, and this drains our empathy meter even more.
However, On any given clinical shift (or call) we have to recognize that we are all individual cogs within a machine, that cannot make impactful change on the system as a hole. All we can do is provide the best care to the patient in front of us – and that is the job. Focusing on the negative aspects of our job, creates a mentality that makes us begin to resent our work, as a result of the system around us, and this takes away from the empathy and energy we have to dedicate to our patients, and to be frank – none of the system issues are their problem, nor should they be.
Historically, medicine has a ‘dislike’ of ‘unconventional’ patients – i.e.: there is often a negative stigma automatically attached to patients who ‘would like to go outside for a smoke’. The problem with this explicit or implicit bias is that it disproportionally creates negative attitudes to select patient populations, and creates no space for the development of empathy or patient rapport.
Similarly, when we feel we are lacking empathy towards a patient, we need to check ourselves to understand if implicit bias is playing a role in our feelings and counter-transference to that patient.
Building empathy IS the long game
When you interview physicians who have had long and illustrious careers in medicine, they often remark that spending time with patients, developing rapport and hearing their stories is the part of the job that gives them the most enjoyment.
There is certainly a skillset in being able to tune out the overwhelming systems-based issues plaguing us in healthcare, and focusing your attention on the patient in front of you – but this is our responsibility to the patient, as professionals, but the more impactful benefit is that the rapport and compassion that one develops from providing patient-centred care will provide greater job satisfaction and can be helpful to mitigate burnout.
There is a perception that providing empathetic or patient-focused care can become increasingly more time consuming, but there is some evidence to suggest that isn’t true. It often only takes a moment throughout our day, and while it may feel like we have many competing interests, we have to remember that taking care of the patient in a holistic way, is part of the job. Further to that, providing care in this way will lead to enhanced job satisfaction, and that is always going to be protective against the negative aspects of working in healthcare.
We build frameworks and safety nets for many things in medicine to ensure that we are not missing things, and these cognitive heuristics help us when are task orientated. Likewise, it is important for individuals to build in concepts of empathy into their approach to patients, and take a moment to reflect on the patient’s experience through their lens.
Whether it is a patient you are seeing, or a patient that you are advocating for, building in cognitive heuristics to ensure you are engaging with empathy, will help to ensure that you are providing patient-centred care, while giving you a greater sense of satisfaction over the work you are doing in an over-encumbered system. With all the current pressures on healthcare providers, sometimes, it is easy to lose the humanity, and remember why we chose this profession in the first place.