Mr. B was breathing fast in his sleep, slumped to the side with an oxygen mask on. The Emergency Department doctor noted his repeated visits for advanced emphysema—and that he continued to smoke. 

I scanned his chart, felt frustration well up, and walked out of the room to compose myself. In the hall, I saw Susan, a colleague who had just spent a week with Buddhist hospice provider Joan Halifax.

“This patient I’m admitting keeps coming back to the hospital every two weeks,” I told her. “He has irreversible lung disease from smoking and can’t stop. It’s frustrating; we’ll never get this guy better.  I am having trouble summoning compassion for him.”

“From the way you are looking at things, you’re right,” she said. “You need to think about your notion of compassion if you want to take care of him… and take care of yourself.”
For years I’ve prided myself on being “in there with my patients.” At times, this produced good results— but often encounters have left me feeling irritated or inadequate.  I assumed this was the nature of the work, but, I also saw it, secretly, as a failing on my part.  Susan was right: I needed a deeper understanding of compassion.

I knew that compassion can be defined as sensitivity to the pain or suffering of another, coupled with a deep desire to alleviate that suffering. Health care is inherently compassionate, and yet the very sense of connection with patients that can make us effective caregivers can lead to feelings of stress and burnout—which then undermines our ability to be compassionate.

This is a paradox that can be broken into two parts. In the first, our work pushes health care providers to jump to problem-solving mode when spending time simply witnessing the suffering is a best first step to help patients. This tension leads to the second part of the paradox: We need to engage intellectually and emotionally with suffering, but we simultaneously need some detachment from outcomes.

How can we negotiate this compassionate paradox? Here are the insights I have gained.

Slowing down

We need to be present with patients in their suffering—to be mindful of what’s happening inside of ourselves and with our patients. What is mindfulness? It is the ability to pay attention to what’s happening at that moment without judgement. It takes practice and there are many forces that undermine mindful engagement.

In the case of Mr. B, I was rushing and looking for a simple answer to his breathing problem—and so I instinctively judged him, which potentially undermined the well-being of both of us. We miss the chance to fully feel compassion when we approach people revved up and in problem-solving mode, instead of seeing them first from the calm, connecting part of our nervous system.

Busy health care providers typically live with their fight-or-flight, sympathetic nervous system running the show when we see patients. As problem-solving healers, our minds are always looking for answers. From the moment I start to gather information about a patient, I am working on the diagnosis. And it is not as easy to connect with patients if our introduction is via data on a computer screen. By the time we set eyes on the patient, we can be looking past the person and instead at the disease entity.

While an image can elicit the hallmarks of compassion in a fraction of a second, research shows that a deeper embodiment of the desire to help and the satisfaction in so doing are much stronger when the parasympathetic nervous system is activated—that’s the “tend and befriend” part of the nervous system.

If we don’t slow down, if we don’t quiet our minds, look and listen, we miss the opportunity to really see what our patients are going through. I didn’t feel compassion or have the urge to help Mr. B, because I let myself get frustrated about his smoking before I had even spoken to him.

So, what we really need is to prime the parasympathetic system before seeing patients. In order to do this, we must slow down our bodies and minds which will quiet the revved-up part of the nervous system. Doing so allows us to get a better sense of the patient’s health problems within the context of their life.

Beyond the urge to help, being in a care-taking, parasympathetic frame of mind leads to the activation of dopamine reward centers in the brain. This gives us the feeling of connection with others, and the feeling of satisfaction bordering on joy that we can get from helping others. Patients need and expect there to be compassion and, in emotionally draining work, we need it too to replenish our energy and desire to help.

With this insight in hand, I have started to take a moment to quiet my mind before each patient encounter and then just listen for a minute or two before allowing my thoughts to start rushing to fix things.

With this insight in hand, I have started to take just a moment to prepare myself for patient encounters.  I take a deep breath and try to calm my body. I then look, not just for signs of illness when I first see the patient, but their emotional state. I often acknowledge their suffering verbally as I ask a few open-ended questions and then I sit back a listen for a minute or two before move to fixing things.

The detachment paradox

Mindfulness isn’t just about being present for those we care for; it gives us the presence of mind to understand our own emotions which is critical to cultivate a sense of detachment.

A few days after seeing Mr. B, I saw a very sick patient I knew well.  Ms. J was 35 years old with metastatic lung cancer. It had spread to throughout her body and she had lost some bodily functions, her hair, and a lot of weight. Now, she was in the hospital with serious breathing problems, likely pneumonia. 

This just should not happen to someone so young. Even to those immersed in the world of cancer, it was disturbing. The patient and her family were thankfully realistic about her prognosis and didn’t want heroic measures to prolong her life if such measures are deemed futile. After talking, we decided to treat this infection aggressively with the hope that this might give her more time.

Her grace in an impossible situation was a thing of beautiful but I still left the room feeling terrible. I asked myself “Had we made the right decision?  Maybe it would have been better to recommend hospice at this point?”  Yet I knew, as is often the case, in these situations, you can never be sure.  Then I wondered, “Where is the connecting and energizing feeling of compassion I hope to feel after a patient visit?”

As I sat at the nurses’ station outside her room, I saw Susan. “The Buddhists say that limitless compassion requires detachment from the outcome of the object of compassion,” she said. “Fully bear witness to suffering, feel moved to alleviate it, but don’t be attached to the outcome.”

This can seem wrong. I really want to help her get better. I need to be invested in making the right decisions.  This doesn’t jibe with detachment. Yet I see that with too much attachment comes a lot of stress. Physicians are regularly tasked with difficult decisions and we have an affinity for those we take care of, yet at the same time we can’t live and die with each patient.

And as is often the case, science supports the Buddhist wisdom. Research on burnout and resilience among caregivers in the face of suffering demonstrates that detachment is associated with less distress. But what amount of detachment would be right?

This dilemma has been at the heart of medicine forever, yet until recently, most physicians could not even articulate this question. Some try to limit all feeling toward their patients to avoid pain—but miss on gifts of compassion. Others might attach too much to everyone and risk being traumatized by repeated feelings of grief. For many, a particularly tough case like Ms. J can lead to “secondary traumatic stress.” This is a PTSD-like process where a bad case sticks with the provider and makes it hard to keep giving emotionally and ultimately to losing the joy of the work.  Mindfulness and the compassion training can give you the tools to work on it—but ultimately, it’s up to you to draw the line within yourself.

It is difficult to navigate the emotional terrain of the work, but the mindful intention we set when first encountering our patients is how we find this delicate balance. I can recognize my anxiety about making the right decision; I see my stress might be in part from fear that my wife could end up with cancer like Ms. J.  I can see the burden all the suffering brings to bare on us as caregivers. And with a calm understanding, I more easily let it go rather than live with nameless anxiety. The presence of mind to understand our own emotions in the face of much suffering is key to creating some detachment.

Not surprisingly, researchers are interested in helping providers remain compassionate in the face of much stress and suffering. Early work by Richard Davidson demonstrates that people with years of meditation training experience much more compassion and at the same time, returned to a calm baseline much faster.  This has led to a number of interventions, all mindfulness based, to promote compassion and resilience. These interventions vary in intensity and duration; who is best served by which type of intervention has yet to be sorted out, but increased activation in the brain’s reward centers upon seeing suffering can be seen in less than a week of training.

At the institutional level, there is broad acceptance of the importance of compassion. Every healthcare organization references compassion in their mission statement and expects compassion from staff. However, while some training programs are teaching compassion, in most organizations no efforts are made to help providers truly understand it.  We need our institutions create an environment where providers can learn to foster a mindful presence, understand their own emotions, cope with uncertainty and then express compassion—that is deeply felt by patients—as they maintain healthy detachment.

A week after first seeing Mr. B, I am called to the ER.  He’s back.  Short of breath again. This time I ask questions—and I listen to the answers.

“Life is tough, doc. I can hardly walk across the room on a good day. My daughter tries to help but all her problems make it worse. Hard to keep trying. All I can do it pray, Doc. That’s it.” he says.

“You are suffering.”

“You know it, doc”

“Well, I will be praying for you,“ I reply. He smiles from under this oxygen mask as I leave. 

Our treatments might get him a little better for a few days, but I know we can’t cure his lung disease. I did provide something else. I have witnessed him without judgement. I took the time to listen and ask questions.  I got a more personal glimpse of his life. And in return he shared his struggles—a humanizing gift to me that will keep me going through another challenging day at work. 

Beyond this small reward, with these new insights at hand, I see not just the “boundless compassion” that the Buddhists promise, but a future of deeply rewarding work.  When suffering suffuses the work, the personal insights and self-compassion mindfulness fosters is essential to keep healing with care.

 

source https://greatergood.berkeley.edu/article/item/the_compassion_paradox_faced_by_health_care_workers