A significant proportion of healthcare providers, especially those engaged in diabetes care, display features of physician burnout and/or compassion fatigue at some time. Development of compassion fatigue can not only affect the provider–patient relationship and patient outcomes, it can also be detrimental to the professional and personal wellbeing of the diabetes care practitioner. In an expert interview, Gagan Priya highlights the factors related to the development of burnout and compassion fatigue among diabetes care providers and delves into strategies to overcome the same.
Q. What is empathy and how can it lead to compassion stress?
Empathy is the innate ability to understand the suffering of another, with a willingness to help and promote the wellbeing of the person. Empathy enables human beings to share their experiences, needs, and desires and promotes pro-social behavior. It would not be inappropriate to state that empathy is a necessary attribute among diabetes care providers. Being empathic toward the patient improves the patient–provider relationship, helps the provider understand the needs of the patient, and improves patient satisfaction and adherence, thus resulting in better outcomes. At the same time, this would lead to fewer medical errors, greater self-esteem, and greater professional satisfaction for the provider.
However, empathy also involves the investment of emotional energy and personal resources of the healthcare provider. The brain regions involved in empathic reaction include anterior insula, anterior mid-cingulate cortex, somatosensory cortex, and right amygdala.1 The anterior cingulate cortex is also activated during directly experienced pain. This region is involved in the regulation of several automatic processes such as blood pressure, heart rate, and activation of stress response. The neural networks involved in experiences relating to self and others are similar and automatic. The right supramarginal gyrus helps decouple our perception of self from others. Thus, there can be two responses:
- “Bottom-up approach”: involuntary, automatic, affective reaction; and
- “Top-down approach”: voluntary, controlled, cognitive reaction.
The caregiver’s response to empathic reaction can be either adaptive or maladaptive:
- Adaptive response: There is increased release of oxytocin, endorphins, and estrogen, along with feelings of care, empathy, and devotion.
- Maladaptive response: There occurs increased sympathetic arousal and increased cortisol secretion, which leads to feelings of burden, depletion, and resentment over time.1
A maladaptive response can lead to the development of compassion stress, i.e., stress resulting from exposure to a traumatized individual. A related terminology is secondary traumatic stress, which is an extreme state of tension and obsession with the emotional and physical distress of the patient.
Q. What is compassion fatigue?
Compassion fatigue was first described among nurses in emergency units as “having lost the ability to nurture.”2 It is a state of exhaustion and biological, psychological, and social dysfunction, resulting from prolonged exposure to compassion stress.3 Compassion fatigue causes the caregiver to disengage from patients and affects their ability to feel empathy and provide appropriate care.
Burnout refers to a state of mental, physical, and emotional exhaustion.4 Burnout and cumulative compassion stress over time can progress to compassion fatigue, with a depleted ability to cope with stress. The progression can be checked by compassion satisfaction or the pleasure one gets from being able to help others. The process is progressive and cumulative.
Q. How can we suspect compassion fatigue in diabetes care practitioners?
There may be physical symptoms such as headaches, fatigue, aches and pains, digestive problems, or the inability to concentrate and focus. Other warning symptoms include feeling sad, sleep disturbances, irritability and loss of temper, avoiding work, absenteeism, judgement errors or low self-esteem. The problem may get aggravated due to poor work performance, conflicts in inter-personal relationships, depression and even substance abuse.5
Q. How common is burnout and compassion fatigue among diabetes care practitioners?
Almost one-third of healthcare providers report burnout at some point in their career.6 Younger physicians and females are more vulnerable.7 Diabetes care practitioners are particularly vulnerable to the development of compassion fatigue. Since diabetes is a chronic disorder with multiple comorbidities, requiring long-term care, a diabetes care practitioner is closely invested in the patient. The onus of motivating patients to adhere to lifestyle modification and medications, keep regular follow-ups, and especially the need to convince them to accept insulin injectable therapy is one of the most demanding tasks. This is compounded by the inability of the patient to see direct outcome benefits and several misperceptions and myths of patients and their families. In addition, use of less reliable alternative therapies is quite prevalent, which often delays timely initiation of appropriate treatment. Therefore, a diabetes care practitioner remains in a constant fire-fighting mode.
Q. What factors render some healthcare practitioners more vulnerable to compassion fatigue?
Some individuals are more vulnerable to compassion stress and fatigue over time. However, this vulnerability itself is dynamic and the individual may be at risk sometimes while more immune to it at other times.4 Several factors work in tandem and include personal factors, patient factors, and work environment. Stressors in personal life, strained interpersonal relationships, previous exposure to self-trauma, long working hours, or a stressful work environment are just some of the factors that can drive a practitioner toward burnout and fatigue.6
Q. Can compassion fatigue be prevented?
Compassion fatigue can definitely be prevented by conscious cultivation of ‘resiliency skills’ among healthcare providers. It is imperative that diabetes care practitioners focus on their own wellbeing as well. In fact, this has been iterated in the Revised Declaration of Geneva, 2017: “I will attend to my own health, well-being and abilities in order to provide care of the highest standard.” There are several strategies to increase resiliency of self.7 Stress-management training, learning positive coping skills, mindfulness or structured meditation and yoga, acquisition of communication skills, and cognitive reappraisal skills are some of the strategies that may be helpful.8 Time management and optimal utilization of available resources to offload oneself is likely to improve efficiency and reduce individual burden.9 The practitioner should establish avenues to unwind and re-energize periodically and build his/her own support group of family, friends, and/or peers. It is also important for healthcare establishments to focus on caregiver wellbeing in addition to patient welfare.
Q. How can compassion fatigue be managed?
A timely diagnosis is important. Compassion fatigue and burnout can be measured using validated psychological tools, such as the Professional Quality of Life Scale.9 Healthcare practitioners need to be made aware of the not-so infrequent occurrence of compassion fatigue. An early appreciation of the problem would lead to prompt initiation of corrective measures.8 Reduction of workload, offloading work, and efficient time management are some of the strategies by which the practitioner can reduce their burden. Learning positive coping skills, cognitive appraisal, and stress management techniques are useful.8 Periodic breaks and engagement in activities to re-energize oneself cannot be stressed enough. Seeking professional help and support from family and friends is also important.