What happens when you run out of empathy?

A closeup of a backlit illuminated gas gage with the needle indicating an empty tank on an isolated dark backgroundby Sam Schueler, MD

I am outside the room where my second-to-last patient of the morning in my primary care clinic awaits me. I will refer to him as Mr. P. We have not previously met, but a review of his medical records reveals that he was recently diagnosed with metastatic prostate cancer. Even more recently, he was diagnosed with multiple myeloma, which was discovered during a hospitalization from a complication of his metastatic prostate cancer. He is actively receiving treatment for both conditions, and documentation from other providers suggests he has suffered greatly from both complications of his underlying conditions and side effects of his treatment. Further review informs me that he does not speak English, and he just moved to the United States this year at age 62.

I went into medicine for the opportunity and privilege to serve patients like Mr. P. However, as I gather myself outside his room, I feel frustrated, burdened, and fatigued.  I know that linguistic and cultural barriers will make every part of Mr. P’s office visit take a long time. I know the severity and complexity of his medical problems will require much more of me in the categories of building rapport and expressing appropriate empathy than a simple, “Welcome to the clinic, how is life treating you?”, before getting down to the business of age appropriate evaluation, screening, vaccination, and etc. I find myself wishing that I was about to see a healthy 30-something-year-old patient who speaks English and is familiar with the United States health care system, while simultaneously being ashamed of having such thoughts.

In medical school, I didn’t experience the aforementioned frustrations with patient care.  The amount of patient encounters and overall responsibility bestowed on me during my clinical rotations never hit a critical mass at which point I ran out of natural empathy and compassion. It all felt natural, and outwardly my sentiments and persona among colleagues reflected my feelings, which led to my induction into the Gold Humanism Honor Society as a medical student. I felt I deserved this honor, and more broadly I felt a sense of comfort and security in knowing I was cheerful and upbeat within my chosen profession.

As I approach the midway point of my internal medicine residency at a safety-net hospital, I struggle with the reality that I run out of natural empathy and compassion all the time.  Outside of Mr. P’s room, I was mostly thinking about myself and my concerns, and moments like this have become a regular occurrence for me.

Ironically, I was again inducted into the Gold Humanism Honor Society (as a resident physician member, chosen by the medical students) shortly after I started writing this piece. This time, I wasn’t so sure I deserved it. The induction included participation in a panel, where we answered questions from fresh 3rd-year medical students about to begin their first clinical rotations. One student asked the panel this question:

“Is it okay to cry with your patients?”

…My internal dialogue said:

“Crying? That is your concern?  What about the opposite? What happens when you don’t feel any empathy? Or worse… what happens when you have negative thoughts?”

I envy the individuals who are filled with compassion throughout each and every day – I think my medical-school-self was one of those people, and he might have regarded this writing as jaded and disheartening. I am coming to terms with this internal struggle, and now more than ever appreciate the importance of family, friends, and other outlets that help me regain my spark. But at times even the best rejuvenation is short lived, and motivation again wanes. Did I choose the wrong profession? Am I a phony, covering up a sad truth with a fake smile and practiced mannerisms?

I did my absolute best for Mr. P that day.  Like many of my patients, he humbled me by being polite, composed, kind and grateful for my care despite all he was experiencing. Like all of my patients, he deserved my best and more. I didn’t necessarily feel like being in the clinic during that encounter, but what I’m realizing in hindsight is that the way I felt is mostly irrelevant. I’m still digesting this, because in medical school my recollection of my training in humanism mostly involved discussing and reflecting on feelings. But humanism isn’t defined by feelings; it is defined by actions. It can be resistant to the waxing and waning emotions we experience on a daily basis. It represents both a code to guide action, and an ideal to strive for, and it is what I had left to rely on when my tank of compassion was running low outside of Mr. P’s room. It is as much about professionalism and duty as it is about compassion and empathy.

I didn’t say anything in response to the aforementioned question from the 3rd-year medical student; fortunately other panel members addressed her concerns.  If I could answer her question now, I would say that it is okay to cry. It is also okay to feel emotionally blunted or feel anything in between. But perhaps what is more relevant is to learn to accept your own feelings regardless of what they are, and what is absolutely more important is not to let them get in the way of providing humanistic patient care.

SamuelSchuelerSamuel A. Schueler received his B.S. from Cornell University and his M.D. from SUNY Upstate Medical University. He is now an internal medicine resident at Boston Medical Center.