Compassion Fatigue: Medicine's Newest Buzzword

Hey, it's been a while.

As I'm sure none of you have been able to tell because I definitely don't have any semblance of a following yet, nor will I probably ever (not trying to appeal for sympathy; it's actually just the reality of paying for the cheapest create-a-website plan possible and putting absolutely no effort into advertising this), I've been on a little bit of a writing hiatus recently. Not intentional, I just haven't been inspired. Some might even say fatigued...

It's not that I haven't seen things, as the frequency of emergencies and life-altering days hasn't shown itself to let up anytime soon, but I was already in a writing rut when one of the most devastating cases stumbled, well actually, ran, into our ER. I didn't have it in me to write about it at the time, so I sort of got stuck not writing. It also felt wrong to try to twist the worst day of someone's life into somewhat of an educational comic. I don't write this stuff as entertainment, by the way, but even so, it's the tone I try to write in to spin lessons out of life. I might try to put that day into words at some point, simply so I don't forget it, but for now, I want to respect that day as someone else's. Though I learned a critical lesson in medicine, I'll probably have to keep it to myself.

Sorry to blue-ball you all with that information, as I am sure I’ve just made you very annoyingly curious, but instead, let’s shift to today’s insight, however long it’s been coming. And apologies in advance, it’s going to be a long one. Compassion fatigue. Now, I called it a buzzword in the title mostly because it sounded cool, but I’m not actually sure if it can be classified as one. That’s because, honestly, the only place I’ve ever heard, or rather, read, this word was in an article about The Pitt. Yeah, that HBO Max show about life in the ED (also, yes, as far as medical TV shows go, The Pitt is pretty dang accurate, just a typical ED on steroids. And that’s not even totally out of the realm of reality, just not my own experience). I didn’t even read the article, but all I remember was, “The Pitt isn’t about '...', it's a show about compassion fatigue.” And I thought, wow. There’s finally a word to describe the phenomenon I’ve been witnessing for the past eight months!

So, my first reaction, funny enough, was to forgive all of the providers whom I had previously been quick to deem rude, dismissive, or downright apathetic, and to shed a new light of sympathy on them. It’s a great thing this term came into my life, because it offers me an alternate perspective when I witness patient interactions that inflict chills of secondhand embarrassment. I think this is a really valuable piece of vocabulary that, if spread to the general public, could really help with the whole “Doctors can really be f**king assholes” thing. So I thought I'd share.

Before I do, I want to say that I hate that a lot of my posts are usually a whole lot of complaining. I do. But alas, to be honest, I’m a pretty cynical person in my everyday life, so let me be. Trust me, it’s mostly a miserable existence, and I’m really trying to change that, but I just want you to know that I’m aware of the sometimes-harsh input I’ve obliged you to endure in this blog. For now, I’ll continue ranting. I really do think it’s productive to talk about flaws in the healthcare system, though. And although most “healthcare sucks” discussions are usually inactionable from a systemic-change/dear-government-please-just-do-f**king-something standpoint, I actually think talking about compassion fatigue can help.

And I know critiquing physicians and healthcare is a dead-horse type of subject, but I feel I might be able to shed an interesting light on these issues. Why? Well, for the past nine months, I’ve been getting paid to be a witness. Sure, I have duties as a scribe, the note-taking stuff and whatnot. But in the ED, there’s a lot of waiting and watching. It’s not like I’m in a clinic seeing 25 patients one after another; I’m in the Emergency Department, where first patient encounters are usually brief, if, you know, it's not a red-phone type of case. We need your chief complaint along with a few key details, and then the provider needs to put in your workup orders and move on, quickly, so that we can evaluate emergencies in a timely manner. The provider gets to see the patient a few more times to update and reassess them, but by then my job is done.

So, once all the department’s beds are filled, workups are pending, nothing is moving, and everyone’s just waiting on radiology to read the dang CT, there’s a lot of waiting. A lot of sitting. My least favorite part of this job. But it’s allowed me to watch, listen, and observe the dynamic of the hospital. I’ve overheard a lot of conversations: nurses, residents, attendings, med students, hospital leadership, staff. In this way, scribing has allowed me a front-row seat to everything behind the scenes. And I hate to be a "Negative Nancy" but, I’m usually pretty disappointed.

What can I say? I’m a victim of the Dream. You know, the dream of healthcare being a place where everyone is compassionate and caring and nice all the time? And I want to be clear, it mostly is. I don’t think this many people would be torturing themselves in this profession if they weren’t compassionate and caring at their core. Now, there are a few leak-ins of people who think there’s money in healthcare (usually the business-minded, non-medical staff of the hospital), and maybe others who are just doing it because it’s a job and we kinda need one of those to live. But don't worry, the majority of healthcare workers most likely went into it because they actually wanted to help people. The forbidden, don't-say-that-in-your-medical-school-interview-come-up-with-something-fun-and-original-because-you-can't-possibly-want-this-job-if-you-just-wanna-help-people cliché.

Let's be honest though, down to the nitty-gritty, it's a job of service. It’s medical hospitality. It’s being a medical waitress. You’re tending to the needs, and a lot of times, requests, of patients. You’re taking their order (history), inputting their order (workup), and then when their order is ready (medications, meals, bathroom trips), you serve it to them. Then you check on them a couple of times to see if they need anything and if everything’s okay, then you give them their receipt (discharge instructions, prescriptions) and send them on their way.

In fact, in many ways, the hospital is like a fancy restaurant. You have a host or hostess managing seating placement (registration and check-in staff), one server who comes to greet you and take your drink order (triage), a waitress managing your order (provider), table runners who bring you the order (nurses), and bussers who clean the table once you’re gone (nurses and cleaning staff). Now, what do hospital staff not have that fancy restaurants (hopefully) do? Hospitality. Ironic, right?

In all fairness, most schools don’t spend a lot of time teaching bedside manner. Usually, it’s something you either have, or you don’t, and interviewers are supposed to choose the people who just have it. But again, some slip through. And sadly, in my experience, I have seen the majority slip through.

Time to really dive in. When I look back at my time in this job, I often remember the most devastating cases first, that darn cynicism peeking through again!

The first that come to mind are obstetrics related. And in case you didn't know, we usually see miscarriages on the non-acute side of the ED. System designed by a man, you know the vibesss!

Anyways, maybe it’s the female perspective I bring to the encounter, but I have yet to see a truly compassionate interaction between a provider and a woman who’s miscarrying. That's probably because, unsurprisingly, I am almost always with a male provider when we see these patients, so of course I'm perpetually disappointed! Now, add in the fact that women’s health is largely disregarded in the ED (who am I kidding, it's disregarded in medicine in general! (who am I kidding, it's disregarded in general!)), and you've got a real feminist shit show.

Now I should say that technically, and luckily, I have personally not witnessed any to be life-threatening, emergency cases, because normally the woman is early in her pregnancy, but regardless, they should still be treated as such due to their emotional implications. And if pregnant women presenting with vaginal bleeding and lower abdominal pain not getting placed on the acute side of the ED isn’t presenting the issue clearly enough, let me tell you a little story.

I was working for an attending one day, which meant that in addition to writing notes for their personal patients, I was also writing their attending attestations for the residents' patients. Therefore, each time the resident presented their cases to the attending, I’d listen in. At one such time, one of the other providers, a male, mind you, walked up, clearly wanting to speak with the attending. Super common occurrence. So, as he was waiting his turn, we both listened in on the resident’s presentation.

At that point, I had already skimmed the patient’s chart enough to know the basic story, that she wasn’t sure she was pregnant, but it had been over a month since her last period and she had really been trying for a baby with her husband. Her pregnancy test was negative at home, but she thought it was just because it was early. She came in for vaginal bleeding and passing a "blob"of tissue, wanting to know if she had miscarried. As the resident presented this information, I heard the lurking male provider start to snicker.

I had witnessed him being dismissive of similar complaints before, so I knew his laugh was mal intended. Becoming increasingly fed up with this type of behavior and finally feeling comfortable enough to voice it, I stepped in. I looked him straight in the eye and said, in my most admonishing tone, “What’s funny.” Question mark intentionally deducted. I was demanding, not inquiring.

I think he immediately realized he was talking to a woman who was not amused, yet he still continued to snicker as he said, “That.” I clenched my jaw, waiting to see if he was going to say anything else. “She’s probably not even pregnant. It’s just ridiculous.”

I replied, “Well, she was trying to have a baby, and her last period was over a month ago. She also passed some tissue with the blood. It's not something to laugh about.”

After that, I just shook my head, eyes pointed toward my screen, and eventually, after one last heavy breath through his nose, he stopped. I left it at that. But I was fuming inside. It wasn’t the first time I’d seen this behavior in him, in anyone. With other providers, I’ve had similar situations where a woman comes in with vaginal bleeding in the setting of pregnancy. It’s usually met with an eye roll and a lackluster response to the situation. Here's another story.

One of the first miscarriage cases I had written a note for. I was with a male provider.

41-year-old woman coming in for the chief complaint of vaginal bleeding. She was seven weeks pregnant. It was her fifth IVF and her first successful pregnancy.

She was in shambles by the time we walked in. Pacing the room with a tear-streaked face, and notably, alone. She told us she believed she was having a miscarriage because she had been bleeding and passed some "tissue." She held a wad of toilet paper tightly in her hands, slowly opened it up, and showed us what she believed was products of conception. Now, if you winced when I said that, you're probably a man. If your heart broke a little bit, hey girl. It was when she used the terms "products of conception" that she revealed to us that she was a hematologist oncologist upstairs, and that maybe if she hadn’t waited so late in life to have a child, she might not be having so much trouble...

I'll take this opportunity to share a sort of a general lament of mine, not really related to the compassion fatigue thing, but it feels important to share at this point. Growing up, I was always interested in cardiology. When I expressed this out loud, someone very close to me looked at me incredulously and said, "That's a very hard specialty for a woman. I wouldn't go there." I immediately pushed back, of course. "Why hard just for a woman?" He said "You know, the hours are really hard. If you want to have a family, it would be very difficult." Instead of describing the rest of the conversation and the argument that then ensued, I'll let you in on my lament: Male physicians have babies left and right here. Residents, even med students are having children. And I wonder if people in their lives tell them it's impossible to have both.

I haven't met one female student or resident who has been a mother, in any specialty, thus far. 

Back to my story, you know what the provider said? And I wish you could have been there to hear the way it was said in the utmost of casual tones, "Yeah, uh, I'm sorry this is going on. Let's get your work up started. I'll be back later." I had to linger in the room a moment just to make sure I had understood what just happened. To see if he might add something. A hand squeeze. A light touch. A hint of actual f**king compassion. I would've taken fake compassion, but nothing. He just walked out of the room. I tried my best to convey my sorrow with my eyes from behind my surgical mask. I looked at her, deep in the eyes and said with (real) compassion, "I'm so sorry." Then I reached for her hand, squeezed it, and rolled out with the computer. I had never felt so helpless. 

I'll say this: there's not much we can do in the Emergency Department for these women. They usually come in sent by their OB for a stat ultrasound, but these women come in desperate, hopeful, frightened, and usually in tears. They should be met with compassion. But not once have I ever been satisfied with the response from the provider. I can’t recall being with a female provider in these instances, but I’m sure it wouldn’t be the same dull, obligatory “Sorry this is happening.” Mind you, if delivered sincerely, can be a comforting line. But so far, I’ve never heard it that way.

I remember another time we saw a patient for vaginal bleeding in the setting of pregnancy, but she was a little farther along than those I had seen previously. When she started speaking, I immediately picked up her Brazilian accent. Again, her tears were met with a flat reaction from the provider, who didn't offer words of comfort at all this time. So as I turned to exit the room, I just had to say "Brazil or Portugal?" She replied "Brazil." I said, "My mom's from São Paulo. Brazilians are strong. You'll get through this." She managed a smile as I walked out, and I felt content that I was able to make her smile for what was probably the first time that day. 

Now, are these examples of compassion fatigue? Maybe. Maybe not. And alas, the central question lies here: Is it compassion fatigue, or simply a lack of compassion?

Let me define compassion fatigue for you. According to the American Psychological Association, compassion fatigue is the burnout and stress-related symptoms experienced by helping professionals in reaction to working with traumatized people over an extended period of time. Psychology Today says compassion fatigue can affect the most dedicated workers, people who continue to help by working extra shifts or foregoing days off, neglecting their own self-care.

Sounds pretty reasonable, right? Spending all day, every day, with people who are usually not the most chipper and are often undergoing the worst day(s) of their lives is exhausting work, and I mean that in the unselfish way, but it can be hard to maintain a positive attitude in such an environment. The negativity can rub off on us, so I get it.

I asked my dad, with forty years of experience in medicine, how he balances it in the outpatient setting. He said, "I'll tell you, it's hard. I gladly spend an extra twenty minutes explaining the difference between two medications so a patient can make an informed choice, but when I get to the next patient's room, they yell at me for having to wait so long to be seen. As if I'm just twiddling my thumbs in the other room! I can never win." See how compassion fatigue can be unavoidable here?

Sometimes I can get pretty frustrated with patients myself. Lots of people are rude. Lots of people are impatient. Lots of people forget their basic social skills when they step foot inside a hospital. Lots of people come in demanding too much. It’s just like bad customers in a restaurant— there’s always someone who’s that guy.

In my humble opinion though, compassion fatigue occurs when a few bad experiences with rude customers become the standard to which everyone is held. Patients are no longer given the benefit of the doubt. Staff are immediately on high alert when a patient walks through those sliding doors. 

Now, I keep feeling the need to make disclaimers and asides to annotate my own remarks, because one thing about me is that I can nearly always see both sides of a story. I make an effort to. Perspective shapes experience. It affects everything. And above all, I just want you to know that I see both sides here, but I’m just one person who tends to overanalyze people and situations, so forgive my cynical point of view.

Someone else might accept these phenomena without questioning or even noticing them, but I, for one, was raised to take note when people are not being exceptionally kind. I notice when a provider barely takes a second to introduce themselves before launching into their placated version of “What are you even doing here?” I notice when providers fail to offer even a glimpse of sympathy. I notice when they complain about people being dramatic or needy.

Because you know what? This job is supposed to be about helping people. At its core, it’s where people come to find answers. And sure, usually they don’t even understand their own question, but it’s the provider’s responsibility to make it legible for them.

It’s possible, too. There are a handful of residents and attendings who are really, really good at taking time with patients to explain their situation and educate them on what’s happening inside their body. But those providers are the minority. That’s what I think is the problem. Instead of being the standard, they’re the exception.

But why are providers forced to limit their patient encounter times, speed up discharges, and skip over patient education? Because of the system that runs it all.

One time, I decided to compliment an attending on the way he spent deliberate, extended periods of time with patients, explaining his entire thought process to them. He takes them through what he’s thinking and explains his differential diagnosis in plain terms so the patient knows exactly what is going on. I saw him draw a picture of the GI tract once to explain some of the anatomy behind a person’s pain. I told him how much I admired it, and his response was, “Haha, thanks, but unfortunately it hurts my efficiency.” He said it in an exhausted, thanks-for-reminding-me, I-need-to-work-on-that-actually type of way, so I immediately knew what he meant. Hospital boards pressuring physicians to cut their interview times, maximize efficiency, and keep the ED moving so more people can be seen and billed. This means less face-to-face time with the patient and more typing on a computer behind glass screens. Beyond that, there's not enough beds. Not enough providers. Less money going into specialties that provide longitudinal care and more going into lucrative, procedure-heavy specialties.

In monthly meetings, attendings’ names are ranked by who sees the most patients in the least amount of time. Yeah, read that again. What kind of message does that send to providers? That they should spend less time with patients and more time ordering expensive tests that maybe weren’t needed if they had just spent more time listening. And it creates a competition where the physicians who incidentally don't provide as much compassionate care are the ones who are rewarded and idolized. 

Here’s another story.

I wasn’t prepared for the night I first watched someone die in the ER.

It was a regular evening, until it wasn’t. A cardiac arrest arrived via EMS: a liver cancer patient who had collapsed in her bathroom. She was in her 60s. Police had started CPR on scene, and by the time EMS arrived, they’d managed to get her back four times. As soon as they rolled her into the trauma bay, her heartbeat was gone again. On the stretcher, a mechanical CPR device beat down on her chest, hard. Her eyes were open, but stagnant. For a moment, I thought there might be hope.

The next few minutes were a blur of action, sound, and medical jargon. The machine kept going, but soon the nurses switched it out to do manual compressions and clear some space. I watched as they managed to get a rhythm back for a second. To the experts, it was nothing, but to me it was something. Then her heart stopped again.

That’s when her family came in.

Chairs were placed right at the foot of her bed, in the middle of all the chaos. Her husband and children were seated in them, waiting. This wasn’t just a code anymore. This wasn’t just a patient who was going to die. This was someone’s family, someone’s future, someone’s grief unfolding in real time.

I thought, This might be the first time I watch someone die.

The cardiology resident was the first to talk to the family amid the commotion, so of course I took notice. He was insisting they not do anything drastic, nothing extreme. He was basically saying he did not recommend taking her upstairs for intervention. It felt like he was pushing them towards the hardest decision they’d ever have to make. And let me also say, he didn't do it with a lick of sympathy. I thought: If that were my mom on that table, I’d never want anyone to give up on her. I wouldn’t care what the doctors say. I wouldn’t want anyone to stop. And at first, her husband fought back. He pleaded for them to do more, as much as they could, everything. He was also clearly not fully aware of what was happening or what was being asked of him in the moment. The way I saw it, they were telling him she was dead before they had even exhausted all options. 

Then, through the steady beeping of machines, compressions, and the frantic shuffling of feet, the husband spoke, his voice breaking. “Stop. Just stop.”

The room froze.

The cardiologist immediately yelled, “He said STOP!”—a little too eagerly for my taste. I grimaced at this reaction. Just seconds earlier, he had been on the phone with his attending, referring to the patient’s husband as “the husband” who “wants us to do everything,” in an exasperated tone that made it clear he was annoyed with this poor man’s request that they try to keep his wife alive a little longer.

All I could do was walk out of the room. It was over. My hands shook. My chest felt tight. The tears were coming fast and uncontrollably. It wasn’t only her death that got to me, but the way the resident handled it. I was angry, and I was disgusted. I wanted to reach out to the husband and say, I see you. I see your grief. Let us explain.

The cardiology resident didn’t stick around to say another word to the family. After urging this patient’s husband to quit fighting for her, he just left. He got what he wanted, and before I could blink, he was off to answer another page, walking casually down the hall to another department.

In that moment, I understood something about this work that I hadn’t quite seen before: Death in medicine isn’t just about the body. It’s about the decisions: the unbearable, raw decisions made when the patient can’t speak for themselves. When the machines can’t save anyone anymore. I thought about how it must feel to make that decision for someone you love. To know when to stop fighting, when to finally let go. How much courage must be hidden in the heart of a person who can make that call. I have no idea what it’s like to face that choice myself. Of course, I never want to know. But I admire the quiet strength it takes to say “stop,” even when every fiber of your being screams for more.

I drove home that night with my face streaked with tears. On top of it all, I was frustrated with myself for crying when it seemed no one else present was as affected. I kept wondering: Am I too weak for this job? Am I the one who has something wrong with them? Am I not cut out for the emotional demands that come along with this profession?

On a practical level, I knew it would not be my last death. But I told myself I would let myself feel all the feelings this time, get all my tears out, and grieve the loss of my first patient as a symbol for all those to come. I know I won’t be able to cry every time. I’ll have a job to do. But I also don’t want to abandon the part of me that broke a little bit when I saw what I saw.

And the whole point of this rant is to reflect on the reasonableness of my sentiment. Are these just the naïve thoughts of an inexperienced person in healthcare? Perhaps. But when I think about it, I’m no stranger to misfortune.

I grew up with a parent with a chronic disease that had to be monitored and managed every minute of every day. I grew up being scared to ask that parent to carry me as a toddler, afraid it could trigger a deadly low blood sugar. I grew up worrying about him every day. I’ve traveled to other countries. I’ve seen the way people live in communities without the resources or infrastructure to live without systemic disease. I’ve worked in private practices, in hospitals, in the EMS system, and now in the Emergency Department. I’ve witnessed despair. I’ve witnessed loss. I’ve experienced death, both personal and patient. I’ve dealt with personal loss: of self, of a person, of hope.

And still, I’m here, struggling to comprehend how some people in this job are so careless. So nonchalant. So unperturbed. It's easy to blame that on compassion fatigue. But again, is it compassion fatigue, or simply a lack of compassion?