If you find yourself in a criminal court one day, make sure your lawyer presents your case to the judge in the morning or right after lunch. Several studies have demonstrated that judges are more lenient when they are well-rested or have just eaten. By late morning, the judge has become weary of defendants and their excuses, and this is compounded by increasing hunger.
Emergency physicians are similar to judges. We hear about the misfortune of patients. Many of them are truly unfortunate, and deserve kindness and compassion. Many, however, are there because of their inability to make good decisions. They missed dialysis. They ran out of their medications. They started drinking or using drugs again. They missed their follow-up appointments. How we respond to each of these excuses is a function of how much empathy we have to give. It goes without saying that one or two difficult patients at the beginning of a shift can drain your compassion. This makes you volatile and ready to rip into everyone else for the rest of the day.
We bring a certain amount of empathy with us on each shift, which I refer to euphemistically as the empathy bucket. The net balance of this bucket is dependent on many factors. Did you sleep well? Did you get in a fight with your significant other? Did you have breakfast? Did your dog relieve himself on the carpet on your way out the door? Is this your fifth night shift in a row? You only have so much of yourself to give before empathy fatigue sets in.
The definition of empathy fatigue by Counseling Today, a publication of the American Counseling Association, is that it “results from the combined psychological, emotional, mental, physical, spiritual, and occupational exhaustion that occurs when anyone is continuously exposed to illness, disability, trauma, grief, and loss.” (Jan. 1, 2013; http://bit.ly/2r9Qtt0.) Sound familiar? We have all been there, and we all get closer to the bottom of our empathy bucket with every patient.
I have made an effort as a program director to get as much intel as possible on which residents in our program are struggling inside or outside the hospital. I enlist my chief residents to keep an eye on the flock and let me know who is cracking. There are some obvious stressful scenarios like when interns first move to town to start residency or when a resident has a child. But other situations are less obvious, like when a resident breaks up with a long-time partner or is “playing too much” during his time off. These issues surface when a bad evaluation is generated, and my subsequent discussion with the besieged resident often leads to tears and confessions of being overwhelmed.
Listen to the Elders
Take my advice: Look at and listen to your attendings. We are very fortunate at my place to have older faculty members still punching out shifts after more than 25 years. Most of them are pretty happy, and the most successful ones stay in shape, eat a good diet, do not spend more than they make, and get enough sleep. They make a point of spending time with their families, and they do not work too many long runs of shifts.
This specialty may seem like a sprint, but it is not. A career in EM is about pacing yourself. As a resident, you have been on a treadmill for most of your life. You changed locations every three to four years, moving through high school, college, medical school, and residency. You changed “jobs” when you advanced from one year to the next through all that education. But as you progress in residency, you finally start doing more of the same thing every day by spending increasing amounts of time in the ED.
It is vital that you look at this as preparation for what you will do for the next three to four decades. There will no longer be regularly scheduled moves after you finish residency. You will take a job and most likely stay in that position for a long time. Even if you change jobs, you will still do the same type of work. The good news is that you will become a master of not letting the tough patients eat up so much of your empathy. The bad news is you will bring a lot less of it with you to work each day. Just as your physical and cognitive skills deteriorate with age, your ability to refill your empathy bucket will also decline. The nicks and dings from years of biting your tongue as you make endless compromises will take its toll.
Observe your elders as you go through residency. Think about aspects of their lives that you can emulate to stay mentally, physically, and emotionally healthy. This will help you meet the empathy demand of your patients in the future and keep you from burning out over the course of your career.
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