Dr. Frank Gabrin is a contributing writer to the The Pulse, ACOEP’s (American College of Osteopathic Emergency Physicians) flagship publication which provides members with the latest ACOEP news, conference updates, in-depth opinions and analysis by leaders in the field, case studies, and information for medical professionals at every level of their career. This article was originally published in April 2015.
The Medicine of Compassion
For decades we’ve worked to keep our “professional distance” in order to maintain our “clinical objectivity” and be better doctors. Yet, in spite of our efforts, at the end of the process we’re left emotionally drained, unhappy and burned out. Our patients are also left flat and unsatisfied. It seems our current practice of medicine isn’t working on either side of the stethoscope.
The big question is why? Previously, we’ve not taken into account how our brains and bodies are hardwired to function in the context of our interpersonal encounters. This is relevant to our practice because the latest research is showing that our most basic human physiology (hardware) is in direct conflict with the current model of care (software). These two aren’t working well together and don’t produce good results, especially for us doctors. What this means is that our hardware and software are incompatible and in desperate need of an upgrade.
It’s impossible to avoid the pain of affective empathy
Science is beginning to show us, through the exploration of our own human neuroanatomy, neurophysiology, neurochemistry and neuroplasticity, that we’ve been misguided and hurting ourselves by clinging to the notion that we can distance ourselves from the pain we’re confronted with every day. What we’re trying to do is impossible.
This is because, deep underneath our cognitive awareness, when we come into contact with another human, we automatically connect to whatever they’re feeling because of our hyper-vigilant survival based MNS [Mirror Neuron System]. This connection happens automatically and, unfortunately, no matter how hard we try, there is nothing we can do to stop it from happening.
This primal “process” happens almost at the level of our brainstem. It puts our brains and bodies into a state of “affective empathy”, where we can’t help but feel what others are feeling. We have no conscious awareness of this almost instantaneous process. We inherently feel pain when we see pain on the faces of our patients, their concerned family members and even the emotion on the faces of our colleagues and co-workers.
Our brain experiences their pain as if it were our own. The same neurons fire when you are in despair as when you witness someone else who’s hurting. In our brain, imaginary is real. The same nerve bundles and circuits light up for real or imagined events. Think about the last time you saw a horror movie. Our brain doesn’t distinguish between physical, emotional or imagined pain.
The pain we feel when we’re disrespected or hurt emotionally by another is the same as when we cut ourselves with a knife while preparing dinner. Which one of us has not experienced heartache or a stomachache without out having a blocked coronary artery or a peptic ulcer? All pain is the same for our brain. It doesn’t distinguish between the pain of a broken bone or a broken heart.
It’s impossible to avoid the pain of affective empathy. By the nature of our work, we’re repeatedly confronted with more and more people who’re in physical or emotional pain. With each encounter, the more we suffer from empathetic overload.
In empathetic overload, our centers and circuits that register pain are continually activated and reactivated. Our brains become drained and depleted of the neurotransmitters that allow us to feel good. In our bodies, cortisol levels rise through the roof, our autonomic nervous system is hyper-activated, our blood pressure goes up, our pulse quickens and our breathing becomes shallow.
The resulting effects are that we feel on edge and our tempers can become short. We’re pushed to the point where one more stressful event could break the camel’s back. How can we be at our personal best when we’re stressed and suffering? Yet this is exactly what our patients need and are looking for in their doctors.
“Cognitive empathy” is how we begin to override the effects of empathetic overload
What can we do to escape from this debilitating state of affective empathy? The answer is clearly not in continuing to do what we’ve been doing. Stepping back, trying to stay clinical and focusing on performing the history and physical, ordering the tests and medicines, making the diagnosis, administering the treatment or making the disposition, doesn’t lessen the effects of affective empathy. If this were the case we would all be feeling great about the amazing work that we do each and every day, but we’re not feeling good. Good doctors are feeling bad almost all the time.
The way we override the effects is by allowing the empathetic process to evolve naturally away from the state affective empathy. By stepping back and trying to disconnect from the pain, we effectively shut down the process. If we were to let it progress, our human curiosity would lead us naturally to the next step where we begin to wonder what going on within our patients and what feels like to be in their shoes. It’s here, in this thought, that we begin to transform the painful effects of affective empathy.
By allowing our curiosity to lead us this next step, we enter into the phase that researchers are calling “cognitive empathy.” It’s from here that we move from the brainstem and lower levels of our neuroanatomy to the level of our prefrontal and frontal cortexes where we have conscious control. “Cognitive empathy” is how we begin to override the effects of empathetic overload.
The emotional frequency of compassion is different than that of empathy
We can’t possibly shut down our feelings, but we can take conscious control over them and use them to our own personal advantage and, more importantly, to the advantage of our patients. By stepping into the pain of others and allowing our curiosity to wonder what it’s like for them, we naturally begin to move away from that painful empathetic place and into the next natural phase of the process, compassion.
Compassion is defined as the emotion or feeling that arises when we’re confronted with another’s suffering and feel motivated to relieve that suffering. Although compassion and empathy are both emotional responses to suffering, they are not synonymous. They are part of a spectrum. Try to think of our emotional spectrum much like we understand the spectrum of visible light. Light is light, but some light is perceived as yellow, others as green or purple,and different spectrums of light have different effects on our physiologic system. Our perception of light as red or blue depends on the frequency of the energetic wave.
The emotional frequency of compassion is different than that of empathy. On the lower end of the spectrum lies affective empathy, which refers more generally to our automatic experience of the emotions of another person. In the middle lies cognitive empathy, which is seen as our ability to take the perspective of and feel another’s emotions in the context of their position. On the highest end lies compassion, which arises when those feelings and thoughts include our desire to help.
Compassion can’t fatigue
It’s through compassion that our system gets upgraded, as its effects are incredibly positive. Research shows that when we feel compassion, just feel it, no words or actions, our heart rate slows down, oxytocin, dopamine and other positive neurotransmitters start to be elaborated in our frontal cortex and the centers and nuclei that register pleasure begin to light up. (A similar thing happens when we eat chocolate).
Not only do we feel better, we do better. Spatial perception becomes heightened and this opens our awareness. We see more possibilities and become more open to novel solutions. Our physical strength is enhanced. Vagal tone is augmented. Heart rate variability re-emerges. Creativity is amplified or augmented and we become more resilient. Math and higher cognitive functions improve. Integration and diagnostic abilities improve.
We become more tolerant and able to see past cultural differences. We become more trusting of others and we’re able to see the interconnectedness between people and situations. It’s when we say something or act within this heightened state of compassion that we can truly make a difference and feel that what we do or say, actually matters.
The process of True Care
Imagine how this uninterrupted process fits into an upgraded model of care that I call True Care:
First, we get fully present and connected with our patient. Next, we focus on our patient’s situation and become aware of the automatic experience of affective empathy within us. Then, instead of turning away from the discomfort, we consciously step deeper into the interaction, letting our curiosity lead us into the state of cognitive empathy, where we try to feel the pain of their situation as if it were our own.
It’s from here that the feeling of compassion is naturally generated by just wanting things to be better for our patient. Our brains and bodies will begin to be flooded with the positive effects of compassion and we can say or do something that will make things better for both of us both emotionally and physically.
Although a lot is happening in this process, we actually go through these stages in just seconds. Once we’re lit up with the positive effects of compassion, we can get quickly get back to the tangible physical process of delivering the goods and services that comprise the entire spectrum of modern medicine.
With a better understanding of affective empathy and by focusing our efforts on effectively using the process of connection and compassion, we can treat the diseases of compassion fatigue and professional burnout. Compassion, this milk of human kindness, is inherit within us all. When we access it, its affect on our human physiology is more powerful than any drug mankind has ever developed. As it turns out, compassion can’t fatigue, it is in fact the ultimate medicine.
Compassion in Action
I’d like to leave you with a personal experience of compassion in action.
Clinically, I work in a busy emergency department that sees somewhere between 200 and 230 plus patients a day. Recently, on a night shift in disaster, I was put into the role of physician in charge. There were 23 patients in the lobby who’d been waiting for hours and every case was complicated and intense.
We were working as hard as we could to get it under control, but it seemed we weren’t making a dent in the number of patients waiting to be seen. At about 2:30 in the morning, I approached a consultant I needed to get two of my patients admitted to the hospital. When I asked for his attention, he put his hand up in the air and said, “Take a number, you are third in line!”
He refused to listen to me at all. In that moment, I felt defeated and deflated, and I actually became very angry! I started to feel like a victim of circumstance. As I worked to contain my anger and get back to the business at hand, I looked up at the clock and it was 3:30AM. This is the point in the shift at which we lose staff and bed space. There were still 22 patients waiting in the lobby.
As I was in charge, I was feeling pretty much like a failure. It was in this very moment of self doubt that the other overnight physician came to me to tell me how completely overwhelmed she was and how she was going to resign in the morning because it was just too hard, too chaotic, and too out of control!
When I asked what was happening, she told me the trouble she was having trying to get her infant patient the treatment she needed. This patient had been here for hours, and how no matter how hard she tried, she wasn’t getting anywhere.
Her anguish was undeniable and she broke into tears of frustration. I felt her pain. They had just placed several new patients into her rooms, and she just could not get to them. I could understand why she was ready to throw in the towel and walk away.
Suddenly, I was larger than usual
What happened next surprised even me. I had such empathy for her. I could not help but share her suffering. My connection to her lead me to that place where I understood her pain and naturally wanted to help her. My arms just automatically opened up and I hugged her.
She was caught completely off guard by my gesture. I told her not to worry, that I would go see those patients in her rooms and that she needed to focus all of her attention on getting that baby what they needed. She went about the task at hand and I grabbed my scribe and went to see all the patients waiting for a doctor.
At this point, my desire to make things better for that baby, and for her, automatically took over. I viscerally wanted things to be better for everyone. It was as if, suddenly, I was larger than usual.
Everyone seemed to be following my step. The entire staff was working even harder to help each other to get the job done. The next time I looked up at the clock, it was 6:30 in the morning. Although the squads had never stopped bringing us more and more patients, the lobby was empty.
My previously distraught physician had gotten what she needed for the baby. She was back to herself and seeing patients that were supposed to be mine. She was now helping me. She was smiling and actually seemed relaxed. Everyone was feeling better, patients and staff alike. This same shift where we’d both been feeling like a victim and a failure had transformed into a night of triumph through compassion in action.
Looking back, I see how I naturally moved through the process of “true care.” When she came to me, I was present for her and automatically felt her pain (affective empathy). I set aside my own situation and put myself in her shoes and felt, as if it were my own, her frustration with the situation (cognitive empathy). Then I made the conscious decision to move beyond the pain and into the holy grail of compassion.
There is nothing better than this
This model of true care, especially in the most challenging of circumstances, changes everything, not only for others, but mostly for ourselves. Compassion enlarges and empowers us as humans. Positive neurotransmitters begin to flow and pleasure centers in our brains begin to light up as we’re transformed from zeros to heroes. What amazed me the most, was the effect that my feeling of compassion had on the rest of the staff. Compassion is emotionally contagious.
By upgrading our model of care to one that is compatible with our human physiology, we can move past the painful effects of affective empathy and into the positive flow of compassion. We will experience the difference our care makes. This is what really matters to those of us who chose to work in healthcare. In my humble opinion, there is nothing better than this, except maybe great sex or chocolate!
Until next time, go care, make a difference and change (y)our world.
All the best-
Frank D. Gabrin, D.O
Back from Burnout: Seven Steps to Healing from Compassion Fatigue and Rediscovering (Y)our Heart of Care
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