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The 3-Fold Harms of Compassion Fatigue During COVID-19 Surges

Published:February 04, 2022DOI:https://doi.org/10.1016/j.amjmed.2022.01.023
      Among the sad pandemic lessons learned is that empathy—like ventilators and personal protective equipment—is a finite resource. Nearly 2 grueling years of work in overstrained and understaffed hospitals have left many health workers overwrought. Terms like compassion fatigue and coronavirus disease 2019 (COVID-19)-related burnout have gained currency in our discourse and comprise the mounting emotional burden levied on health providers as the pandemic wears on. Compassion fatigue refers to the depletion of empathy from high-volume, emotionally ponderous caseloads with inadequate time to recharge from patient care duties;
      • Decety J
      Empathy in medicine: what it is, and how much we really need it.
      the latter term, burnout, may exist on a continuum with compassion fatigue but is characterized by marked demoralization and cynicism.
      • Shanafelt TD
      • Hasan O
      • Dyrbye LN
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      These phenomena are lamentable, albeit understandable: COVID-19 has evolved from a disease of frontline workers and vulnerable populations to a disease of the willfully unvaccinated. More frequent encounters with an increasingly entrenched unvaccinated population threaten to deplete an already scarce resource: compassion. Compassion fatigue, at scale, could entail dire consequences for our patients, our healers, and our profession writ large.
      This emotional toll, though not well quantified, is well-illustrated: An infectious disease physician is scornful of the illogic of critically ill patients who eschew a lifesaving vaccine and later demand “everything” be done when their lives are imperiled.

      Sircar A. As a doctor in a COVID Unit, I'm running out of compassion for the unvaccinated. Get the shot. Los Angeles Times. Available at: https://www.latimes.com/opinion/story/2021-08-17/vaccinated-covid-doctor-shot. Accessed December 27, 2021.

      An emergency department doctor writes of his seething anger at media personalities who have inoculated his conservative community against the evidence undergirding the efficacy and safety of COVID-19 vaccines.

      Davidson R. I'm an E.R. doctor in Michigan, where unvaccinated people are filling hospital beds. The New York Times. Available at: https://www.nytimes.com/2021/12/08/opinion/covid-michigan-surge.html. Accessed December 27, 2021.

      An intensivist worries about the effects of this anger, however justifiable, on our ability to be empathetic healers to all who seek our help.

      Lamas D. An I.C.U. doctor's message of hope amid Omicron. The New York Times. Available at: https://www.nytimes.com/2021/12/27/opinion/omicron-hope.html. Accessed December 27, 2021.

      Readers likely have their own troubling experiences caring for patients who have abstained from vaccination against a disease that has caused us personal anguish—sickening or killing friends, family, peers, and patients.
      For health professionals already physically exhausted by successive surges and a sense of endless crisis, these examples illustrate the additional psychological burden of caring for patients whose sense of social cohesion or responsibility to the public good gives way to more individual concerns. There is a distressing disconnect between our ethic as physicians to render care without rendering judgment and the seeming indifference of unvaccinated individuals toward the public welfare. Great moral exertion is required to provide quality care—not to mention empathy—to such patients who socialize the consequences of their personal decisions and carry a gilded assumption that health professionals will always be there for them no matter what.
      Yet losing our empathy could invite secondary harm to patients, irrespective of their COVID-19 status. Data from prepandemic times suggest that medical errors and increased health care costs are more common when providers suffer from burnout.
      • Tawfik DS
      • Profit J
      • Morgenthaler TI
      • et al.
      Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors.
      ,
      • Han S
      • Shanafelt TD
      • Sinsky CA
      • et al.
      Estimating the attributable cost of physician burnout in the United States.
      These patient harms add to the consequences of delayed surgeries, disrupted longitudinal care, crowded emergency departments, and capacity-constrained hospitals that have already burdened all patients since the start of the pandemic.
      COVID-19 burnout and compassion fatigue pose a threat to providers as well. It is well-established that physician burnout is associated with suicidal ideation,
      • Menon NK
      • Shanafelt TD
      • Sinsky CA
      • et al.
      Association of physician burnout with suicidal ideation and medical errors.
      substance use,
      • Oreskovich MR
      • Kaups KL
      • Balch CM
      • et al.
      Prevalence of alcohol use disorders among American surgeons.
      and malpractice claims.
      • Balch CM
      • Oreskovich MR
      • Dyrbye LN
      • et al.
      Personal consequences of malpractice lawsuits on American surgeons.
      Moreover, health workers who entered the profession because they sought to be healers risk emotional scarring when recalling that there were some patients whom they could not care for compassionately out of anger, a need for self-preservation, or a sense of moral injury. After all, we still strive to uphold a virtuous professional creed, and failing to do so could undermine self-esteem. Many in medicine were likely attracted to the profession because of its historical commitment to the idea that physicians can be counted on in a crisis, no matter the time of night, the personal hardship, or the magnitude of the emergency that must be surmounted. If compassion fatigue or burnout limits this commitment, providers risk a hollowing out of their sense of mission and an erosion of long-term career satisfaction.
      Finally, if compassion fatigue means that physicians apply a different standard of care for the unvaccinated, as has been suggested,

      Marcus R. Doctors should be allowed to give priority to vaccinated patients when resources are scarce. The Washington Post. Available at: https://www.washingtonpost.com/opinions/2021/09/03/doctors-should-be-allowed-give-priority-vaccinated-patients-when-resources-are-scarce. Accessed December 29, 2021.

      we risk jeopardizing our standing with a public that for many centuries and across many cultures has granted us special status in society. To declare that there are some patients who are not socially worthy of our best efforts will compromise a binding trust essential to the practices of medicine and public health. Our profession is built on a standard of care for all persons regardless of how they got to be a patient. Our reputation, although not without its historical blemishes, risks irreparable damage if we acquiesce to the heat of the moment and overlook our first principles and duty to the patients in front of us. The public, as well as our trainees, need exemplars of how to comport oneself in a crisis and fulfill our oaths without casting judgment.
      We must continue to counsel our patients and the broader public about the importance of vaccinations, a task consistent with our oath to prevent disease wherever we can. As reviewed elsewhere,
      • Haldane V
      • De Foo C
      • Abdalla SM
      • et al.
      Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries.
      health care leaders and policymakers must do more to improve the resilience of our health delivery and public health infrastructure so that we can do our jobs effectively in a crisis. And meanwhile, we need to learn how to mitigate burnout and compassion fatigue amid the Omicron surge and the ones that follow it.
      In response to physician burnout, many hospitals and residencies have expanded wellness and mental health programs to help physicians and trainees to navigate the inherent stresses of the profession.
      • Card AJ
      Physician burnout: resilience training is only part of the solution.
      Such initiatives are important, but amid a pandemic that has atomized individual suffering by isolating us from our peers and loved ones, we need to rekindle a sense of solidarity with our colleagues and shared purpose in our profession. We also need to provide time and space to validate the extreme frustration and trauma that arises from treating patients with a disease that we have the tools but not the public will to defeat. How to do this may need to be contextualized within individual hospitals, training programs, and even care teams. We find value in reminding health workers that they are participating in a historic moment, that their work matters. Physician discourse convened by trained mediators, as in Balint groups,
      • Mahoney D
      • Brock C
      • Diaz V
      • et al.
      Balint groups: the nuts and bolts of making better doctors.
      can help to normalize the frustrations we feel toward patients and serve as a setting to share them with other doctors. Curricula in medical humanities and history may help trainees rediscover a kinship with each other, as well as with forebears in the profession who presided over past public health crises of similar scale as our own.
      We hope that each of these measures can mitigate compassion fatigue and burnout in this unfortunate phase of the COVID-19 pandemic. After all, empathy, a finite resource, must be replenished so that we can be there for each other and for the patients who need us most. The public, our students, trainees, and those in allied professions are watching us carefully in this crisis. They deserve to see us at our best.

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