Jonny Martell: compassion fatigue

Jonny MartellThe medical school sausage factory is fattening me up and rolling me into shape. Another year has passed. I am gaining knowledge and growing in experience. And losing my empathy.

Apparently I shouldn’t beat myself up over this. It’s par for the course, a common side effect of the rites of passage journey into medicine. The journal Academic Medicine lays it out bare in, “Empathy decline and its reasons, a systematic review of studies with medical students and residents.” Of eleven studies conducted among medical students, nine found a significant decline in empathy over the course of training. 

The reasons provided for this threw up no great surprises.  It seems that medical school, especially clinical training, can cause significant “distress” and it is this that lies behind the fall in empathy.  Situations that might lead to this distress include:

  • “Mistreatment by superiors or mentors: Medical students may experience situations of harassment, belittlement, degradation, humiliation”
  • “High workload: Students and residents face long working hours, with an associated lack of sleep and inadequate relaxation time.”
  • “Vulnerability of medical students and residents: Values of idealism, enthusiasm, and humanity are present in students at the beginning of medical school, but these may diminish as trainees are confronted with clinical reality (characterised by illness, human suffering, and death) and their focus shifts to technology and objectivity rather than the humanistic aspects of medicine.”

Illness, human suffering, and death… in hospitals, who would have thought? 

Brushing aside such crusts of cynicism – surely signs themselves of compassion fatigue – it was interesting to read of a likely candidate for empathy’s neurophysiological correlate, the mirror neuron.  According to one hyphothesis, these can take a beating from the stress of training and their signal rate can reduce significantly. The review cites another study in which doctors’ brains were shown to down regulate “the sensory processing elicited by the perception of pain in others.” As many others have pointed out, such a process might well be an important adaptive pay off: over identifying with patients’ suffering can lead to burn out and bad decision making. The patient suffers more.  

All this begs the question – is this just a normal part of the initiation process into medicine?  Or perhaps medical students are caught up in a larger social phenomenon?  A 30 year long look at American college students found this to be the case.  The review quotes the “emotional anaesthesia” of today’s young people, put forward by the study’s authors as a result of the age in which we live. A part of this is the “information flooding” of today’s communication technology culture that increasingly curtails space and time for the perception of our emotions. (Apologies for this blog.)

On a more encouraging note, studies do point to the possibility of tackling the decline. For medical students, who invariably feel like they should be doing something, sitting around doing largely nothing might be a difficult pill to swallow.  However, it is precisely that, in the form of mindfulness based stress reduction, that shows the most encouraging results for interventions in empathy and stress management. Adapted from Buddhist mindfulness principles at the University of Massachusetts Medical School, this secular meditation based programme performed well in a meta-analysis assessing its role in helping people cope with disability and distress. More recently it has been adapted to create another mindfulness based programme that has won NICE’s backing for recurrent depression. Meditation on the NHS?  As a recent feature in the Independent asks of the increasingly popular transcendental meditation, were the hippies right all along?

In fostering awareness and ideally prevention of impending burnout, these approaches also serve to tackle the prevailing and arguably self defeating ethos characteristic of medical culture.  This is that self denial and performance under stress are inevitable and therefore essential traits of doctors. Given the spate of positive outcomes associated with improved empathy from doctors, I wonder why they’re not teaching us more about this at medical school.

Jonny Martell is a medical student in London.