A little thing called compassion fatigue

Although compassion is central to the practice of good medicine and caring is a major factor in job satisfaction among doctors, there is surprisingly little research on medical compassion. Instead, most research around compassion in medical contexts focuses on instances where compassion is lacking, on compassion fatigue.

But while professional fatigue, occupational stress, and burnout exist and are clearly important – just look at the recent strike by junior doctors in New Zealand – our view is that the very concept of compassion fatigue concept is flawed and risks derailing the study of compassion in medicine.

In many ways, it was our discontent with the notion that “caring is tiring” that led to the research program we now run. Historically, the notion of compassion fatigue has its roots in the study of the burnout and secondary traumatisation seen in response to patient trauma and the need for a more politically palatable label. But think about it for a moment? Is caring (specifically) tiring? Or is it that work/life demands are excessive and the capacity to care suffers as a result? Clearly, we believe it is the latter.

The term itself does not help. When we talk about medical professionals in terms of compassion fatigue, it implies that being compassionate is tiring or depleting in some way, as if we each possessed a finite “reservoir of care” that we draw from in our professional practice. As each suffering patient presents in our offices, we dole out smaller and smaller dollops of care, drawing down from, and ultimately depleting, this mythical supply.

But this notion, that there’s some sort of reserve or that runs out, is inherently problematic. Where does this reserve reside? In the heart? Was it full when we started practising medicine? Or sometime before then; or when we were born? Does it leak somehow? And even supposing that compassion did decline with use – it doesn’t – how do we replenish the reservoir? Suffice to say that, in our view, thinking about compassion in this way is neither accurate nor useful.

Importantly, the compassion fatigue view is inconsistent with evidence that engaging with compassion is pleasurable, increases social connections, and may actually protect against stress. Think of it this way: If compassion fatigue is the result of a progressive depletion of a finite reservoir of care, one would expect compassion fatigue to be greater and more common among physicians who see more patients or have been practicing for longer. In fact, the opposite is reliably true. Not only is compassion fatigue consistently lower in older healthcare professionals, and recent research from the University of Auckland suggest the barriers to compassion are also reliably lower.

In one large study, Vinayak Dev and colleagues measured workload, burnout, and the barriers to compassion in 800+ nurses, 500+ doctors, and nearly 400 medical students. While patient load and overall workload both increased with more clinical experience, burnout (as indexed by the widely-used Copenhagen Burnout Inventory) was consistently lower. More to the point, analyses indicated that the barriers to compassion also decreased with more clinical experience. Barriers were lower in practising doctors than in medical students and were lower in both doctors and nurses with more clinical experience.

Now, of course, it’s possible that the “uncaring” professionals – those who struggle to care – are more likely to retire or that older “cohorts” of doctors and nurses were selected and trained in a way that maximises compassion somehow. As explanations, both seem unlikely. Although the practice of medicine has changed, increasing data attesting to the impact compassion has in healthcare has resulted in an increase in the emphasis on person-centred care and compassion in medical training. More likely, in our view, is that experience brings with it a greater appreciation of patient suffering, a tendency to withhold judgment, and an ability to manage resources so that compassion is maintained. Clearly, such an interpretation is inconsistent with the notion that doctors get tired of caring.

In our view, we need to stop talking about compassion fatigue as if it were distinct from burnout, and (as Trotsky suggested) consign it to the ash heap of history. Caring is a responsibility and a privilege in health. Certainly, care is something that suffers when we are burnt out, but it’s not because we are tired of caring. Along with everything else, it simply suffers when we are tired.

The authors are convening New Zealand’s first ever compassion in healthcare conference at the Auckland Medical School in March 2019. Conference registration is full but information about the event is available here.