The concept of “self” is critical to our wellbeing. We feel it when we are not truly ourselves, we’re off somehow. I recognize that feeling in myself when I’ve become pre-occupied with upcoming project deadlines or when I stop paying as much attention to my true interests and needs. And I think there’s an important conversation to be had in medicine about the challenges to this idea of self because there will come many times in the course of our training that we will question some aspect of our experience; Did I make the right choice choosing medicine? Am I capable of performing well enough? Ultimately, am I enough? These are normal thoughts that many of us experience during our first months of medical school, the well-known imposter syndrome. Despite having worked so hard to get to where we are, we still ask ourselves whether this is where we should be. And with ongoing clinical training, it’s no secret that many medical students, residents, and staff experience burnout and compassion fatigue which creep into our personal lives and clinical practices, silently. 56% of medical students feel some degree of burnout symptoms1 such as amotivation and pessimism to the point of loss of interest and empathy. Burnout has been described as the “three-dimensional psychological syndrome of emotional exhaustion, cynicism, and reduced personal accomplishment”1 that’s seen in many medical trainees. Cynicism has also been described as “depersonalization”, a process of losing touch with oneself and not embodying personal thoughts and feelings as one naturally would in the absence of stress. Furthermore, it’s hard to imagine why this shift might occur without having experienced it first-hand since the clinical environment is where we want to be, engaging with patients in a helpful and meaningful way. Burnout is a complex issue that in many ways reflects a systems problem rather than an individual problem, but it has an enormous impact on the individual.
In medical school, we have to make a few sacrifices in our personal comfort; we might see our families less, we might have less time to plan for spontaneous get-togethers with friends, and we might spend those few hours of down-time resting and recharging rather than working on our hobbies. There will be discomfort manifested in other ways too; breaking bad news and participating in difficult conversations, managing misunderstandings between colleagues, feeling inadequately prepared when faced with a new clinical scenario or task. When these challenges are ongoing and we don’t have the appropriate support systems or resources to guide us through them, we can start to pull back from our experiences and disengage with our patients and tutors, as well as in our personal lives with our partners, friends, and hobbies. Our sense of who we are, as defined by our personal entourage, interests, good health can fall to the wayside. There’s an imbalance when you spend a significant amount of your time caring for others and so little time taking care of your own needs; it contributes to the emotional exhaustion of medical training.
However, I think we are also incredibly fortunate to belong to a community and to come to the realization that everyone is dealing with some version of our challenges. We are surrounded by colleagues who are experiencing similar things and with common experience comes the ability to connect and understand one another, to support and encourage one another in a positive way. I recently came to learn of a meditation practice called loving-kindness, or Metta Meditation, which is driven by self-compassion and love for those around us. Early Buddhist texts discussed four virtues of meditation which included loving-kindness or benevolence (metta in Pali), compassion (karuna), empathetic joy (mudita), and equanimity (upekkha). Metta specifically was the central theme of a text in the Pali Canon (Theravada Buddhist scriptures) called “Karaniya Metta Sutta”. According to the story, Buddha sent his followers into the woods for some time. They returned frazzled by the spirits that haunted the forest and seeing this, the Buddha asked his followers to greet the ghosts with a Metta practise to counter their bad nature. The story ends with the spirits becoming the monks’ protectors and guardians. Here, Metta acts as an olive branch, an invitation into a relationship founded on kind understanding despite any signs of anger or hate being expressed by another.
More practically, engaging with this practice might involve repeating certain affirmative phrases such as “may I be happy, may I be safe” or “may I be healthy, may I be happy today”. During this meditation, the intention is to establish a sense of gratitude for yourself, accepting yourself fully and without judgement. You might take some time to extend that sentiment to someone you have a close relationship with, thinking about the qualities you admire in them. The practice goes beyond the kind, daily thought of I love myself; it has to do with making self-acceptance a go-to state of mind on the daily. It’s about noticing the good things in our lives (peace, health, happiness) and the more negative realities we deal with (stress, worries, conflicts) and holding both in our minds and hearts. It’s not about resting in the illusion that everything about your life is perfect, but accepting that in this moment, this day, this week, this is where you are emotionally, physically, and these are your challenges. It’s about striving to bring more kindness to your intentions towards yourself, to your challenges and to those around you.
I’m not saying that this is the answer to reversing the effects of burnout, but I do believe that the “antidote” to compassion fatigue has something to do with reconnecting to genuine feelings of compassion and empathy, starting by reconnecting to those emotions in yourself since kindness for those around you begins with self-kindness (“physician heal thyself”). And when you’re tired and don’t feel like you can be as attentive, empathetic, or understanding as you might otherwise be, it might seem counterintuitive to ask more of yourself and be especially present with patients. But by doing this, you’re opening yourself to the opportunity to be a part of this patient’s journey and recovery and the interaction will be one of shared healing. Some might argue depersonalization can be helpful as it allows for separation between patient and physician. It means less internalization of heavy emotions and difficult patient experiences. But as with most things, there’s a balance to be found; ultimately, we need to be kind to ourselves, we need to take care of our emotional needs before we are able to be present with our patients all the while being mindful of the boundaries that exist during our patient encounters. Loving kindness meditation is a stepping stone towards that emotional balance.
Here are a few Loving Kindness resources that you can explore:
(1) Kachel T, Huber A, Strecker C, Höge T, Höfer S. Development of Cynicism in Medical Students: Exploring the Role of Signature Character Strengths and Well-Being. Front Psychol. 2020;11:328. Published 2020 Feb 27. doi:10.3389/fpsyg.2020.00328
(2) Salzberg, S., 2018. Why Loving-Kindness Takes Time. [online] Mindful. Available at: <https://www.mindful.org/loving-kindness-takes-time-sharon-salzberg/> [Accessed 12 September 2020].
(3) Chowdhury, M., 2020. What Is Loving-Kindness Meditation?. [online] PositivePsychology. Available at: <https://positivepsychology.com/loving-kindness-meditation/> [Accessed 12 September 2020].
This article was written by Madison Le Gallee, a medical student at McGill University and member of the McGill Med Mindfulness Team.