What happens when you run out of f*cks to give

When I first started locuming as a GP I booked as much work as I could fill my calendar with.

4 days of work a week sounded fine on paper but oh how naïve I was.

The negative effects came on slowly but after a couple of intense months it was impossible to ignore.

I kept seeing this same recurring daily pattern where towards the end of the day I would be completely drained of empathy.

I just couldn’t take in anymore negative emotion, people were sucking the life out of me!

My emotional reaction to the same tale of woe varied over the course of the day like this:

1^st patient: (Genuine empathy)

5^th patient: “There, There”

9^th patient: (Please stop you’re hurting me)

10th patient: (I don’t care anymore) ☹

I’d be just giving and giving and giving until I had nothing left.

I just wanted to get through the list and go home.

This is when I intuitively knew I was working too much.

My empathy was depleted.

What is Empathy?

Empathy is an umbrella term used to cover similar but slightly different experiences.

There’s 2 types of Empathy

Cognitive Empathy:

You can understand what another person feels by consciously taking their perspective. This is essentially Sympathy.

e.g When a patient tells me their partner has cheated on them:

I can intellectually understand that they will be feeling, hurt, wronged, depressed etc.

Affective Empathy:

You actually feel the same emotion that another person feels.

e.g When a patient tells me their partner has cheated on them:

I now feel hurt, wronged and depressed myself.

This is where empathy can become problematic depending on which route you take next…

1)Compassion

Compassion is like an enhanced version of cognitive empathy.

You understand how they feel and additionally feel positive emotion and concern towards them which drives you to alleviate their suffering.

As the diagram below shows, you need empathy in order to feel compassion.

2)Empathic Distress

This is when the feelings you’ve absorbed are too distressing for you. You focus on your own distress and stop caring about the other person.

It occurs as a result of prolonged exposure to negative emotion without adequate time to fill your empathy tank back up.

Over time this can lead to Burnout.

Affective Empathy = You feel like shit so I feel like shit.

Compassion = You feel like shit so I want to help you feel less like shit.

Compassion results in helpful action to alleviate their suffering

Empathic Distress results in overwhelm which disables you or leads to action to alleviate your own suffering.

If you are in Empathic Distress and a patient demands antibiotics for a self diagnosed chest infection you may prescribe them even though you know its a viral infection and the antibitoics won’t help them. However they will help you by stopping them from complaining and getting them out the room.

• Compassion is always positive emotion towards someone else

• Empathy takes on the whole spectrum of emotion from negative to positive

• Compassion is a desire to help someone because you’re concerned.

• Empathy is just being aware of how someone feels but not necessarily doing anything helpful about it or not being able to do anything about it.

Empathic Distress

As Health Care Professionals or anyone in a caring role we are susceptible to Empathic Distress.

Now we know why it happens lets look at its features in more detail to help you identify whether you may be getting stuck in it.

Compassion Fatigue was the first term used to describe Empathic Distress way back in 1992 by Dr Charles Figley.

In 2018 scientists decided they didn’t agree with the term because people don’t get fatigued from being compassionate.

Compassion always feels good! Its love, kindness and positivity, it gives people energy rather than taking it. Empathy on the other hand can take all the energy!

During prolonged exposure to negative traumatic emotions its empathy that fatigues. This is why empathic distress replaces the older term compassion fatigue. But they are both still used interchangeably.

Empathic distress can be an acute reaction that happens every now and then when we have a particularly bad day. Or it can be a more chronic state that people live in when they aren’t able to recover.

Chronic Empathic Distress is a state of emotional exhaustion and depleted empathy resulting from prolonged exposure to suffering and trauma.

It essentially causes a secondary traumatic stress reaction for the carer. This results in multiple symptoms associated with Anxiety and Depression.

Physical and Emotional Fatigue

• You feel tired all the time

• Thinking about work makes you tired

• You find yourself just sat on the sofa the whole evening, delaying going to bed because you know once your eyes close the next time they open will be to the sound of your alarm clock.

Irritability

• You get triggered by the smallest things

• You’re trying your best to hold it all together, but someone or something pushes you over the edge leading to out of proportion emotional reactions.

• This is experienced as mood swings from red hot fury to sobbing uncontrollably within minutes, confusing those around you and yourself.

Social Withdrawal

• You become socially withdrawn

• You feel emotionally numb and have no motivation to voluntarily engage with anyone

• You feel disconnected from others who are having a good time whilst you suffer.

Over time, people may become desensitized to others' suffering, leading to a decline in the quality of care or support they provide.

This can have a knock on effect of causing Moral Distress when you’re aware the care you’re giving is inadequate but feel powerless to do anything about it.

Moral distress is already a common feature for Healthcare professionals working in underresourced systems like the NHS.

This forces us into doing things we fundamentally disagree with or are morally opposed: eg cut corners as lists long, discharge early, not what you were trained for etc.

How to manage Empathic Distress

I hope I haven’t depressed you too much. I can assure you there’s light at the end of the tunnel.

Remember Empathy can lead down 2 paths and that it depends whether your tank is in the red zone or not.

In order to avoid Empathic Distress states leading to negative impacts on our lives we have to do something to stop the tank from getting low on empathy.

Empathise and Detach

The longer you stay stuck in the negative feelings of someone else the lower your empathy tank gets.

Imagine you are seeing a clinic of 15 patients in 2.5 hours, or attempting to anyway.

Lets say within that session you have 5 emotionally charged consultations that result in affective empathy- you feel their negative emotion.

There’s 2 different ways of managing yourself during the session

A) You turn on the empathy for the first patient, absorb all of their trauma and negative emotion and keep it for yourself.

You stay in the same emotional state between each patient, empathising with each of them until your empathy starts to drop off.

By the time the 4th and 5th patient arrive your empathy tank is in the red and you stop being compassionate and move into empathic distress.

B) You turn on the empathy for the first patient, but when they leave you detach from their emotion returning to your baseline emotional state.

You can still empathise with each patient that needs it but because you can turn it off you don’t run out.

Have a detachment ritual

I like to imagine that I have the same power as the Black Panther suit to absorb kinetic energy and then discharge it.

So after I absorb all the patients negative emotion I take a deep inhale and the exhale imagining I’m releasing it all.

Its essentially about having something that you can associate with bad energy leaving or good energy entering.

You could use:

• Music

• Breathing exercises

• Photos of happy memories

• Smells- Your favourite essential oil or perfume fragrance

• Use your imagination to go to your happy place.

Any form of ritual thats helpful to you that you can link to positive emotion and grounds you back in your own life in the present moment.

Just the awareness that you’re feeling the negative emotions of someone else rather than your own can create the gratitude needed to feel better and detach.

Turn Empathy into Compassion

Detachment seeks to prevent your empathy from running out.

But what if you could cultivate so much compassion that it never ran out?

Loving Kindness Meditation is a special form of meditation where you focus on generating feelings of love and compassion towards yourself.

Then you extend these feelings outward, first to loved ones, then to acquaintances, and finally to all beings, including those you may have difficulty with or feel indifferent towards.

This has personally worked wonders for me.

There’s nothing better than the feeling of just being in such a good mood that no one can drag you down.

It effects your whole demeanor and attitude towards people and they can sense it. You can observe someone go from anger and frustration to smiling and laughing with you.

Or see someone go from complete pessimism to feeling hopeful.

I’ll have to ralk more about Loving Kindness Meditation in a future email.

Guidance and Supervision

Obviously it would be great to seek some form of guidance and supervision from someone trained.

You’ll only get so much from ranting to your partner when you get home about it.

Speaking to other GPs that are just as stressed as you can only help so much. You just end up trading stories to compete on who’s had the worse day.

Its helpful in a sense of having social support but it tends to normalise the experience and distract you from being aware when you really need help.

When I did my psychiatry rotation as a GP trainee we used to have supervision sessions with Consultant Psychiatrists.

We had protected time to discuss our most challenging cases and receive support.

We even had a Balint group lead by a Psychotherapist where you had to specifically discuss the feelings you experienced during a case.

At the time I didn’t really appreciate the benefit of it because I found the secondary care Psychiatry setting much less stressful than General Practice.

GPs are exposed to as much negative emotion as mental health workers are and have much less resources to do anything helpful for patients.

I’ve realised we definetely need to be creating protected time during the GP work day to discuss emotionally challenging cases with a colleague who is not also fighting for their life.

Summary

What happens when you run out of f*cks to give?

Empathic Distress is what happens.

• We’ve dissected out Empathy in order to understand how Compassion and Empathic Distress are created.

• We’ve discussed the key features of chronic Empathic Distress

  1) Physical and Emotional Fatigue

  2) Irritability

  3) Social Withdrawal

• We’ve discussed how to manage Empathic Distress

  1) Empathise and Detach

  2) Loving Kindness Meditation

  3) Guidance and Supervision.

I’ve survived multiple long periods of emotionally draining work as a locum GP.

I’ve learnt self compassion really is the key.

You deserve to feel positive about the work you do and live a healthy life.

Take all knowledge here on board and protect yourself.

Thats all for now

Lewis

P.S

I help Introverted Doctors Escape Career Stagnation by being True to Themselves.

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