The Messy

One very late night during my pediatric residency, I sat in the middle of the pediatric intensive care unit with my supervising fellow and the hospital chaplain. A teenager we had been caring for had just chosen to be decannulated (that is, have her tracheotomy tube removed) and be allowed to die. She was 16 years old and lived with a rare neuromuscular disease that had progressed to the point that she could not breathe without the aid of a ventilator and, more devastatingly for her, could no longer paint or draw.

“Some days,” the chaplain said, “we are called to the messy.”

Through the course of my career, I have been advised on how to wade through this mess; how to tend to the hardship, the pain, and the trauma experienced by the humans that we are called to care for and about. Well-meaning mentors have warned me to keep an emotional distance from my patients. Burnout experts warn us all of “compassion fatigue.” Even the language we subconsciously revert to in the emergency department urges separation from human suffering — we care for “the broken arm in room 12” and “the non-accidental trauma in 5.”

This perspective may arise from our deeply ingrained “culture of scarcity”: we can never have enough, know enough, be enough. We fear that our compassion is finite but that we just weren’t told exactly when it would run out. So, we keep pushing and pushing, rightfully unwilling to ration it.

“Our capacity for compassion is endless”

I would like to offer a different perspective. I believe that our capacity for compassion is endless; that we can hold and attend to both the joy and the pain of our work; and that we can find meaning in and be transformed by the suffering we witness. For me, this begins with recognizing the limitations of empathy.

In a study using EEGs and MRIs, a team of social neuroscientists examined the differences between empathy and compassion. In one experiment, the French Buddhist monk, Matthieu Ricard was asked to listen to recorded sounds of a woman screaming with the specific instruction to feel her distress but do nothing more. The pain centers of his brain were active, and he struggled to continue. Then he was instructed to listen to the same sounds but to also engage in compassion meditation — to repeat phrases offering up safety, health, and ease to this person. His pain centers remained activated but so, too, were the neural networks associated with love and other positive emotions. He felt that he could continue to do this indefinitely.

Empathy is affective resonance with someone else; it allows you to feel suffering when they suffer and to feel joy when they feel joy. Empathic resonance alone, however, can lead to emotional distress and burnout. “Empathy,” Ricard writes, “should take place within the much vaster space” of compassion and love.

It is important to unpack this term to understand what it is, how it serves our patients, and how we cultivate it. Ricard wrote beautifully that “compassion is nothing else than love applied to suffering.” Empathy directs our attention to where it hurts; compassion calls us to work to understand the levels of pain, and the manifest and latent causes of it, so that we might effectively help and empower. Compassion calls us to act; to engage with our patients and with our communities.

Cultivating this compassion and sustaining it through the demands of our profession is effortful; caring for self while caring for others should be a daily practice held with the same reverence that you hold doctoring. That practice will look different for each of you. But I urge you to keep these key components in mind:

·         First, pause frequently. Intentionally make space for rest, recovery, and being still. For me, this has looked like asking our team to pause together after a death in the ED and taking back some of the hours lost to my smartphone to be in solitude.

·         Second, stay fully present in your experience no matter how difficult. This is as straightforward as stopping to notice and name the emotions coming up for you during patient encounters. After sitting with a mom who just learned that her 5-year-old has leukemia, it is easy to overfunction rather than recognize how our emotions are impacting us. We are quick to reassure, and to fix, and to plan. Still, if I sit and say to myself, “I am feeling fear,” or “I am feeling anger,” I can remain present for her and let compassion guide my actions instead.

·         And lastly, as the meditation teacher Jack Kornfield wrote, “If your compassion does not include yourself, it is incomplete.”

Compassion in practice

A few weeks ago, I sat with a student during their dismissal hearing. The experience was understandably distressing for them, and I struggled to help. So, I consciously engaged in a practice that I use nearly every shift in the ED, one that some of you have heard me talk about before; I sat across from them and noticed my breathing. With every inhale I thought about breathing in compassion for myself, and with every exhale I breathed out compassion for them. I know that even this small departure from focusing on others makes some of us uncomfortable and makes us feel as if we our abandoning our mission as caretakers. But in that moment, with that student, rather than feeling overwhelmed and reflexively pulling away or trying to fix, I felt only love. And love, far from sentimentality, is the force that undergirds the most important and transformative moments in humankind’s history.

Love is also the way through; we must harness it if we are to continue to alleviate the suffering of others, fight for social justice, and care for our communities and our planet sustainably and intentionally. As I have learned often during my career, patients, caregivers and the world around us are all wading through “the messy.” They each deserve my best efforts to provide them with my mindful attention, my love, and my compassion.