When Empathy Hurts: Navigating Compassion Fatigue Inside (and Outside) Medicine

As a pediatric intensivist, I've cared for the tiniest patients, felt the weight of parents' hopes, and grappled with the ethical complexities of life and death.  Compassion, in this world, isn't just a buzzword, and I don’t think it’s a hard sell to believe that physicians should have compassion for their patients.  No matter how big-hearted we are, we are on the winning side of a power dynamic with our patients: they’re vulnerable and need the skills that we have.  While not a specific criterion for burnout, compassion fatigue is undoubtedly related to one of its indicators, “increased mental distance, or feelings of negativism or cynicism related to one’s job.” (For more about the criteria for burnout, see this AMA piece).

It's easy to feel compassion for the distant struggles we witness.  Unhoused people?  I feel compassion.  People with decompensated mental illness?  Compassion.  Any sort of mailer from the ASPCA?  Compassion explosion.  But what about when it hits home?  When it's your own family that needs your care?  

Recently, I ushered my grandma from the pre-contemplative to the contemplative stage of considering assisted living.  Before I brought it up, I’d put a lot of work into figuring out options.  I’d Googled.  I’d looked at different scores and metrics for what a “good” assisted living facility has.  I’d toured places, and I’d narrowed the list down to the couple she should see.  I had everything figured out.  In my mind, the conversation with Gram was going to go this way:

Me: Gram, the family’s worried about you, and we think it’s time to consider assisted living.

Gram: Really?

Me: Yes.  And we love you so much; we just want you to be safe.  I’ve done a lot of work on this, and I think we should go look at place X and place Y the next time I’m in town. 

Gram:  Oh, that sounds great!  I’m so grateful you’ve put so much time and effort into this!  I’m excited to see what you’ve come up with.

Shockingly, it didn’t go like that.  There was hesitancy.  There was recalcitrance.  There was avoidance.  And did I feel compassion?  I did not.  I felt frustrated.  And irritated.  And insecure.  And embarrassed.  And judgmental.  And when I couldn’t generate the compassion that I feel for my patients (or even an unhoused person I drive past and do not personally know), I beat myself up for being heartless.  Why is having compassion so easy in some circumstances and so complicated in others?

Author and meditation teacher Susan Piver describes compassion as "the ability to hold pain and love in your heart simultaneously."  This struck a chord.  Maybe the reason I’m having difficulty cultivating compassion for my grandma is because the pain is just too close.  I don’t know what it is like to be unhoused, but I know very well how independent Gram used to be.  I also know how frustrating it’s been for her to come into her older age, to become “a burden” (her words, not mine, and she will not let go of them no matter how hard I try).  

It turns out compassion isn't always a warm, fuzzy feeling. Sometimes, it's a raw ache in your chest, this simultaneous holding of pain and love. While I’m letting myself sit in the discomfort, I can see something else: I am also in pain.   Perhaps my struggle wasn't a lack of compassion but rather the discomfort of holding both my grandmother's pain and my own.

So, how do we navigate this?  How do we cultivate compassion without reaching a level of burnout that impacts both our professional and personal lives?  Here's what I'm learning:

Acknowledge the pain:  Both theirs and yours.  Don't brush it aside or pretend it doesn't exist.  And please don’t try to “action” your way out of the pain by doing more research or bringing up the matter whenever you have the chance.  The only way out of feeling pain is to let yourself go through it.  

Embrace the discomfort:  Compassion isn't always easy, but that doesn’t mean you’re “doing it wrong.”  Give yourself credit for acting compassionately, even if it seems small.  Once you see how often you practice it in “small” matters, it’ll give you confidence to have it when the “big” things come up.  

Practice self-compassion:  It’s true; we have to put our own oxygen masks on first.  Prioritize your well-being, set boundaries, seek support, and ask for help.  And acknowledge the love that’s in your pain.  Even if you’re not self-actualized enough to love yourself unconditionally, appreciate that the reason you’re feeling pain over the situation is because you love the other person so much.  

I obviously don’t want to be in pain; no organism does.  We’ve evolved to be afraid of pain.  But if I turn towards the pain that I feel over Gram’s needing more help than I can provide from afar, I can start to feel love.  I love that I care so deeply about my grandma that it’s painful for me to see what she’s going through.  That is pain and love I can hold at the same time.  It’s not comfortable, but neither is what I’m going through when I’m not accepting how painful this process is.  I might as well choose the discomfort that comes with love.  In that, I have compassion for Gram.  And for myself.