Module 1: Feeling the pain: Empathy and action
One of the most challenging things about working in healthcare is coming close to human suffering, sometimes a lot of suffering every day. When I went to medical school, I didn’t have any classes to prepare me for this experience, to recognize it, understand it and work with it. Today there are dozens of studies on what has been identified as healthcare provider burnout. One of the root causes is empathy fatigue–when that suffering becomes too heavy, too exhausting for us to hold day after day. How each one reacts when our patients are struggling also challenges our capacities to help. We even set up some probably not so great habit ways to cope, which ironically can add weight to our already heavy loads. And a few more things how we deal with uncertainty, distractions and good old anxiety don’t help either. This short course will teach you how all of these get in the way of our helping profession, and give you some on-the-go ways to work with them. The course consists of seven modules about 15 minutes a day and that’s it. We’ll cover how empathy and compassion are different, which one burns us out and why, how to work with anxiety, worry and other distracting thoughts, how to work with self-judgment, emotional contagion and even how to work with biases in pain perception. You learn how to jump-start curiosity and as a bonus, you might even learn a little something about how your brain works, so you can put it to work for you, instead of fighting against it when things aren’t going well.
My name is Jud Brewer. I’m an addiction psychiatrist and a neuroscientist. My lab at Brown University has been studying how we form habits and developing behavior change treatments for things like smoking, overeating and anxiety for the past several decades. In the clinic, I treat a range of mental health conditions, specializing in overeating, anxiety and addiction. I’ve written several books that bring together my research and clinical experience, one called the Craving Mind and another called Unwinding Anxiety.
This course is for all healthcare providers. If you are a doctor, nurse, nurse practitioner, physician assistant, physical or occupational therapist, psychologist, social worker, nutritionist, therapist or anyone who works with patients, we all share one common goal: to help people. As a physician, I will be using examples from my own experience and medical training, and stories from other doctors. The lessons apply to all of us in the healthcare field, so I invite you to consider how your own experience fits with the stories you will hear as you go through this brief training.
Let’s get started No matter what your specialty is, to help your patients you have to be able to empathize with them. This may seem obvious. The more you can understand what your patients are experiencing the better you will be at diagnosing, treating and caring for them. For example, if your patient is in pain from a broken bone or a sprained ankle, it is easier for you to have a sense of what that feels like if you’ve had a similar injury. In fact, neuroimaging studies have consistently shown that perceiving or even imagining other people in pain activates pain processing networks in the brain. Empathy is defined as the capacity to understand and share others’ emotions, feelings and mental states by imagining or taking another person’s perspective. This is often described as being able to put yourself in someone else’s shoes. For example, if someone tells you that a certain pair of shoes is painful to wear, but they look comfortable enough to you, it is only when you try them on and walk around a bit that you really see for yourself what this person is talking about. Oh yeah, these shoes are uncomfortable. This makes sense. The more we can walk in our patients’ shoes, the more we can understand their pain, and more we can help them. If you need some data to see how important being able to relate to your patients is, studies have shown that higher “empathy scores” in doctors correlate with better surgical recovery, faster wound healing, shorter hospital stays, and even better blood sugar control in diabetes for their patients. Yet ironically, empathy has been linked to burnout. Perhaps as a sign that we begin developing unhealthy coping mechanisms early in our medical training, empathy has been shown to begin dropping in the third year of medical school and go down from there. Burnout shows up as early as residency at 49%. Beyond residency, up to 60% of practicing physicians report burnout. So, you’re probably thinking, “Ok, the more I empathize, the better my patients do. But the more I empathize, the more likely I might be to get burnt out. Catch-22.
So how can you put yourself in your patients’ shoes so you can feel their pain, without feeling their pain? In other words, how can you personally understand what someone is going through without taking it personally?
In medical school, I learned that empathy was a good thing. More of a good thing should be even better, right? Especially if it helps me be a better doctor. So I dove in headfirst and tried to empathize as much as I could with my patients. It wasn’t until much later that I discovered that empathy has its limits.
Empathy fatigue–sometimes referred to as compassion fatigue–is a real thing. It burns us out. Here’s how.
As a psychiatrist, I need to be able to empathize with my patients. As a behavioral neuroscientist, I study how my patients learn. Most of what we have learned in our lives is turned into a habit. Everything from walking to eating to tying our shoes gets laid down early in life so we don’t have to think about it. This frees up our brains to learn more important things like medical facts and how to care for our patients. You probably studied this learning process a while ago. It’s called reinforcement learning and has two basic flavors: positive and negative reinforcement. As a refresher, it only takes 3 elements to learn, a cue or trigger, a behavior and a result. For example, the first time you ate ice cream as a kid, you probably learned that it tastes pretty good. Cue—see ice cream. Behavior—eat ice cream. Result—learn that ice cream is yummy. That’s positive reinforcement in a nutshell. You learn to repeat a behavior that results in a good feeling, forming a habit.
Sometime later in life, you might have had a bad day. Maybe you didn’t get as high of a score on a test as you wanted. So your parents or friends made you a treat, or took you out for ice cream to cheer you up. Cue—don’t feel good. Behavior—eat something sweet. Result—feel better. That’s negative reinforcement in a nutshell. You learn to do a behavior to make something bad go away. You might be wondering how this psychology 101 refresher course relates to empathy fatigue and burnout. Well, it turns out that over-empathizing can trigger burnout through negative reinforcement. Here’s how it works.
To empathize with your patients you have to put yourself in their shoes. If they are suffering—which they generally are if they are coming to see you—you have to step into their suffering and feel it. Suffering is painful. Note the irony here. To help, you have to feel the hurt. If you do this a lot, you are feeling a lot of pain. Over time, that can burn out even the most resilient clinicians.
Here’s what your brain is processing in these moments: cue—your patient is in pain. They are suffering. Behavior—you empathize, you feel their pain and suffering. Result—you suffer. You might be thinking, “Yup, this profession is all about suffering. I know what that feels like. At least I’ll be good at empathizing with my patients.”
But, if you suffer too much or too long, you get burnt out. How can you avoid burnout? This is where the learning happens. When you start getting stuck in this pain and suffering cycle, your brain kicks into survival mode. Remember, negative reinforcement gets set in motion when we’re trying to get away from something painful. So you start learning how to avoid the suffering or make the pain go away.
You learn—and this usually happens unconsciously—that by distancing yourself from the pain and suffering, you don’t feel it as much. It’s like burning yourself on a hot stove: you quickly learn that heat and your hand aren’t friends. You learn to keep your hand far enough away from the stove that you don’t get burned. Perhaps you learn the same trick in your clinic. You try to get just close enough to your patient’s suffering that you can help, but not so much that you get burned out in the process. Or you mentally armor up to protect yourself, dodging and deflecting the emotional bullets that your patients fire at you. There is even evidence for this. Brain studies have found that physicians inhibit bottom-up processing of the pain perception in others. This neural downregulation may be a marker of these learned protective mechanisms. In other words we do armor up on a mental level.
However, If you stay too far away from the pain, you are at risk of becoming or getting labeled as cold, uncaring, or insensitive. Your armor is so thick that your patients can’t even see you: they just see a mask or an expressionless face or some other shield that you’ve held up as mental personal protective equipment. That mental distancing as self-protection is a key question in the Maslach Burnout Inventory. It’s called callousness. You’re trying to help and not get burned in the process, but by stepping back, you’re getting or at least getting labeled as burnt out. Yes, more catch-22. I know. It sucks.
Here's another survival trick that your brain might learn. Let’s call it the quick fix. Your patient starts describing something that is causing them suffering. They could be in pain. They could be anxious. They could be frustrated with their medical condition or how their treatment is going. No matter what it is, your brain senses that suffering. And your brain, whose primary job is to protect you from harm, senses that things could get worse. If you don’t do something—and do it quickly—they might get more anxious or more frustrated. Then you’re really in for a world of hurt. Your brain urges you to fix this situation as quickly as possible. So you jump into action and refer them to a specialist or you prescribe a treatment if you are that specialist. One of my professors in medical school called prescriptions love notes. Your patients are coming in need of love, and you aren’t showing them that you love them until you prescribe something. Let’s map this out: Cue or trigger—your patient is suffering. Behavior—you quickly do something to try to help. Result—they go off to the specialist or to fill the prescription and you can go on with your day. But then you fall into a habit loop of your own. You start wondering if you did the right thing. You wonder if you listened carefully enough when they were describing their symptoms so that you didn’t miss anything. You hope that you didn’t miss anything or jump to a conclusion about what their diagnosis is.
Ready for a really tricky one? We’ll call it the take it home habit. Let’s say that your patient is suffering. You’ve tried everything. All the treatments. All the referrals. Nothing has worked. They are still suffering. Even seeing their name on your clinic schedule raises your blood pressure or makes you feel anxious. What now? Cue—see your patient suffering. Behavior—can’t think of anything else to do, worry about them, think about them at night, lose sleep over them. Result—feel exhausted, defeated, and burnt out. Now you’re suffering too. It isn’t helping your patient and certainly isn’t helping you. This is the take it home habit loop.
Here’s a variant of the take it home habit loop that a primary care physician told me about. He described how sometimes when we feel helpless and inadequate as a provider and feeling that we can’t help, we can get angry, blaming their condition on them, labeling them as crazy or too demanding. We might even take that frustration or anger out on our healthcare team. He called it the anger loop. Getting angry feels better than feeling inadequate or impotent. He also pointed out how this loop loops back to harm us. We feel guilt or shame for our outbursts, and it damages our relationships with our patients and our staff.
And these are just some of the most common solutions our brains come up with. They are to some degree, natural reactions, but they all have one thing in common: that when you are caught up in these habitual ways of responding, you lose perspective, the emotional toll is draining and you are less effective at helping your patients. The more you get stuck in these loops, the more likely you are to get burned out. I’ll name them again so you can remember them.
1. Over-empathizing loop: your patient is feeling anxious, frustrated, angry, hopeless. You empathize a little too much. You feel these feelings a little too much.
2. Self-protection loop: You armor up or distance yourself so that you don’t get burned.
3. Fix it loop: You jump into action, you have that strong urge to do something, do anything.
4. Take it home loop: You worry, you can’t stop thinking about your patient or your decisions.
5. Anger loop: You get frustrated or angry and lash out at your patient, staff, or family.
The Maslach Burnout Inventory has two dimensions: emotional exhaustion and cynicism. Can you see how all of these loops fit? Over-empathizing and taking the suffering home drive exhaustion while self-protection leads to cynicism. Frantically trying to fix things probably contributes to both: you are frantically trying to fix the problem as a way to run away from the suffering. No matter how good of physical shape you’re in, even marathon runners can’t run forever. Voila exhausted cynicism.
Recent research on physician resilience has found correlations between the inability to decompress and burnout. Put slightly differently, the more that you are able to let go and detach yourself from your job when you are at home, the more likely you are to take care of yourself, get a good night sleep, and recharge your batteries for tomorrow. Getting in the habit of charting or checking work email late at night drains your mental batteries much more than saving you whatever time and energy you think it will get you. You’re probably already exhausted from today’s module, trying to map out all of these loops, but I’ll throw one more into the mix: Cue–think about how behind you are on work. Behavior–check a few emails or do some charting late at night, promising yourself you’ll limit it to 30 minutes and then go to bed. Result–getting caught up in your work, not getting enough sleep, and being exhausted. It makes even harder to stop and you get caught in this transient repeat mode, one more, just one more email, one more chart. You end up a zombie the next morning, feeling drained and cursing your job.
I don’t even need to mention the bit about how doing work at home does not gain points with the family. Most of our workplaces have squeezed things like charting out of our schedules so we’re forced to bring work home with us. On top of this, we’re more likely to snap at our partners or spouses when we’re stressed and tired, and might even use work as a shield or an excuse to run away from problems at home. More habits hide here: work triggers family stress and then work becomes the escape from the stress it caused. That’s messed up.
So, back to why we all got into healthcare: to help people. It is really hard to find that balance where you can empathize with your patient but not over-empathize, not take on their pain. Not take their suffering personally. I’ll suggest that there is a way to feel pain without taking it personally. In fact, there is even a method to tap into your brain to help you find that balance that can leverage this same habit loop process to help you step out of unhealthy habits and into ones that don’t drain and even can charge your batteries as you go. You’ll learn how to do this in the next couple of modules. But first, it is really important to be able to diagnose yourself: to be able to see when you are getting sucked into a survival habit loop, like the ones I described above.
Here's how to do a quick self-diagnosis. Remember that survival is about self-protection. When you touch a hot stove, your muscles contract so that you quickly pull your hand away. You step back from the stove. This is what self-protection feels like: you step back, you contract, you close down. Think about the last time someone criticized the care they were getting, questioned your judgment or verbally attacked you. Did you flinch, mentally close down or feel the urge to get away? This is the natural reaction that we all have when our brain registers danger. And this closing down or distancing ourselves is not a sign that you are a bad clinician or aren’t going to be able to help your patients. It’s just what we learn to do in the face of suffering. We close down, we distance ourselves.
So here’s the practice for today: See how well you can diagnose or recognize when you are in any of these habit loops: over-empathizing, self-protecting, fixing, taking work home or maybe one I haven’t named. Don’t worry about what cued it. Start with the self-protective behavior. What's the behavior? Can you notice when you are closed down or turning away? If it is a fix it loop, can you notice an urge to do something quickly? If it is the take the suffering home loop, can you recognize when you are worrying or carrying your patients suffering around with you? What are your most common loops? If helpful, you can download this empathy habit loop mapper and carry it with you to map these out as you go through the day, or take a few minutes at night to reflect back on your day and map them out when you have time. Onward! We'll see you tomorrow.
References:
https://www.medscape.com/2022-lifestyle-burnout
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Howell, Thomas G., et al. "Physician burnout, resilience, and patient experience in a community practice: correlations and the central role of activation." Journal of patient experience 7.6 (2020): 1491-1500.https://pubmed.ncbi.nlm.nih.gov/33457606/
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