Giving less and less…

I want to talk about something that’s a little awkward to talk about. It’s something that affects EVERY healthcare professional, and it’s something we need to talk more about. I want to talk about compassion fatigue, empathy exhaustion, professional burnout, or as I like to call it, giving less and less of a fuck!

All healthcare professionals whether working in the private or public sectors are challenged with providing patient-centered care in an efficient and effective manner. They have to do this whilst trying to embrace and implement evidence-based practice, meeting productivity goals and targets, maintaining high professional and personal standards, and usually with limited support or resources.

These daily challenges are a constant struggle for many clinicians that can and do lead to increasing levels of stress and frustration, that can and do affect their physical and mental health and impact on their quality of life.

stress

I know this first hand. I have been doing this job for over 15 years, and for nearly every day of those 15 years I have been listening to patients stories of distress, suffering, frustration, and confusion about pain, injury, or surgery. And for nearly every day for 15 years I have been trying my best to help, support, encourage, and motivate these people find a way forwards, onwards, and upwards with what ever aliment or condition they have.

But it’s tough, really tough.

Year on year, month on month, day on day I can feel and sense a change in my approach in how I manage many of the patients I see. This is not only due to my knowledge and experience growing and evolving or the changes in evidence, but also due to my own compassion and empathy fatigue. To put it brutally honestly I can feel myself giving less and less of a fuck to more and more people I see.

In the beginning way back at the start of my career I was lead to believe and truly thought I could help everybody I saw, and I tried my damn hardest to do so. However, I soon realised that my education hadn’t prepared me for the many brutal realities, hardships, and disappointments that this job brings. I was unprepared for the feelings of frustration and failure I was getting with many of my patients, and I felt like it was my fault.

However, I don’t feel like this anymore. I still try my damn hardest to help all those I see, but I find myself better at accepting and recognising that I can not help everyone. I now know there are many patients who I won’t or can’t connect with, who I won’t motivate, encourage, educate, or help!

You may think this is unprofessional to talk about, and that as a healthcare professional I should try everything I can, with everyone I see. And I agree, every patient deserves the best possible care they can get. But this is my pragmatic realisation over the years, this is my compassion fatigue, this is my giving less of a fuck.

Or is it?

I’ve learnt with time and experience that there are many patients who are not ready or willing to be helped, that some patients don’t want my advice or help? I have learnt from countless past failures who I can, and who I can not help. I have learnt over the years that there are many patients who despite saying contrary are reluctant to put in the effort or commitment to help themselves for many reasons, and that any attempts I make to assist them will have minimal to no effect on their problems or issues.

I also know that no matter how hard I try, I can not, and will not bond, connect, encourage, or motivate everyone that I see. I also know that no matter what I say, or do, or try, I will make very little difference to some patients no matter how much I do connect or how motivated they are. But I also now know this is NOT my fault.

Many patients think we need to fix them.

We don’t “fix” anything. We don’t have magic hands that heal things, we don’t have healing powers, or other supersitious clap trap. Physios simply offer advice and education to those willing to listen and learn. We simply try to facilitate a change in our patients lives and their problems. We try to encourage and motivate patients to move more, and we use physical activity in all its glorious ways and means to do this.

Magician wand

Many patients need to understand that having good physical and mental health, and being pain free is not an automatic entitlement. Many need to understand that a shit load of hard work is required to maintain a healthy body and mind. Many need to realise that it takes a lot of effort to reduce the risk of disease, deterioration, and decline.

Human bodies are designed for activity on a regular, daily, hourly basis, and many simply don’t do enough, nor do they want to. This is fundamental in everything we see and do as physios. If patients are not ready to accept this, if they are not interested and invested in their own health and outcomes, then I will not waste my time and energy on any patient who thinks I should be more interested and invested in their health and outcomes than they are.

You may call this harsh, I call it realistic!

Don’t get me wrong, I’m not saying we should all of a sudden become hard nosed bastards and throw everybody on the metaphorical scrap heap of ‘life’s no hopers’ at the first barrier or hurdle we encounter with their motivation or effort. Rather that we should be more realistic in how much we can help some, and how much we can’t help others.

I think we also need to recognise that as healthcare professionals we have just as many issues and factors as the patients we are supposed to be helping. Of course most healthcare professionals are empathetic in nature, but this is not limitless. We all have a finite amount of energy and enthusiasm, and we all need to use it wisely and appropriately. There is nothing worse than wasting your ‘mojo’ on someone you can’t help, and then having none left for those you could.

Being aware of our own mental and physical health as a healthcare professional is paramount. If you are not looking after yourself, you wont be any good at helping others. If you want to be in this job for the long game you need to work out how to manage this in a way that is right for you.

single-malt

For me I find having a good social network is paramount. Having colleagues, friends, and family that I can talk too, moan too, bitch too, let of steam too is vital, and this blog. It is all cathartic for me. Physical activity and exercise is also vitally important. If you as a clinician are not letting off some steam and stress on a treadmill, a sports pitch, a road, or a weight room at least a few times a week, be prepared for some hard times ahead. Eat well and sleep well. Finally don’t take life or physiotherapy too seriously, and enjoy those you love and who love you. I also find a good glass of single malt whiskey every now and then helps tremendously.

In summary I feel physios and other healthcare professionals don’t talk about ‘not giving a fuck’ and most think it is a taboo subject. For me it is the ‘elephant in the room’ that is affecting us all in some small or large way. So let’s talk about it more. I think there is very little recognition or support from our professional bodies or employers in regards to compassion and empathy fatigue. Instead the focus is always on the pressures and demands facing the patients, eg waiting times, budgets, costs etc. These factors tend to comes at the price of asking clinicians to see more patients with less time and resources without considering what effects this has on the clinician. This is a recipe for disaster, because if you don’t look after those who look after others, things are never going to get any better.

As always thanks for reading

Adam

78 thoughts on “Giving less and less…

  1. Pretty ballsy Adam and as always spot on. It’s a taboo subject but getting it out in the open is a bold move. Couldn’t agree more. We’ve all got to take it a little easy on ourselves to be able to offer the best we can. I make it a habit to tell all my new patients that I’m all out of magic fairy dust. Maybe that’s why some don’t come back…………..

    • Thanks for that Adam, it was refreshing to see a lot of what i have been thinking and feeling for many years put down in words.
      Especially the frustration of the people we see who expect us as clinicians to take full responsibility for them getting better. I try always initially try my very best but that dwindles quicker and quicker over the years with those who can’t or won’t hear or do what they are being advised.

  2. It’s important to have a strong team around you. I find a multidisciplinary team hugely supportive when feeling this way. My experience of unidisciplinary teams was more professionally competitive.

  3. Until recently I was a dentist for over 35years. When I was feeling like this I would think of the patients as people with a parcel under their arm. The parcel was their problem/s, I would do everything in my power to help and could feel very empathetic, but never pick up the parcel.

  4. Adam,

    Thanks for this blog. I can relate to all of the things that you are talking about. I have been practicing for almost 20 years (holy crap!) and became very burnt out about 10 years ago. That was after I finished my manual therapy certification. I slowly realized that this wasn’t the be all, end all. As I learned more about pain science and came into contact with different physios, I learned to take the pressure off of myself. It’s still a work in progress. I have to remind myself to watch out for the “energy vampires” during my day.
    Nowadays, I can combat the stress of a difficult workday with some heavy metal, a beverage or two and knowing that other therapists are in the exact same boat. Thanks for your writing.

    Aaron

  5. Brilliant. Well said and I completely agree. I have done this for 18 years and you just said exactly how I feel. Fucking spot on. Keep up the good work and pick your battles.

  6. Totally agree Adam.

    As clinicians we have a limited energy level and is best used to direct and guide without taking on emotional burdens eg guilt, for not solving all and sundry problems. I like the ‘coach and student’ analogy. The coach can analyse the weak areas of their student, design up and teach specific drills to overcome the deficiencies, but can’t actually do the drills. No point as it isn’t the coaches problem to correct.

    From AAP Education’s research with new and recent graduates, this area of clinical fatigue/burnout is one they really struggle with. We have identified 5 challenging client personas that potentially drain their energy levels and teach them through scripts and role plays how to positively deal with them.

  7. Hi Adam,

    Thanks for writing this, I needed to read it. I get myself physically ill (and presently am) from giving too much of a fuck in the treatment room, trying so hard to convey how important it is for clients to just get moving and then stressing about how I could (or in a lot of cases could’ve ) done more.
    Once I’m back at work I will begin to try and actively decide if this client gives enough of a fuck for me to as well. Though everyone will get the same care and listening ear I will not try to make rocks go uphill on my own, the client must push with me.

    Cheers again.

  8. Hi Adam
    As a recently qualified sports rehabber I am really enthusiastic at the moment but this is definitely something I have noticed in others and wondered how long it would take for me to feel like this!
    For me it’s all about empowering patients to take responsibility for their own body and health and giving them the tools to do this. Where they go from there is down to them.

  9. now then, once again, good points, all well made! a lot of the comments make sense as well, we have become a nanny state. I have noticed more and more people are being referred with pains that they’ve had for DAYS, sometimes self referring with pains for HOURS! its extraordinary. People just will not accept pain, they want rid and still believe we have magic hands. If I had a quid for everytime ive heard someone say “I want you to fix it, take my pain away, heal me!”
    im not sure where this all ends though, to me, the public are becoming more dependant, despite evidence, despite folk like us screaming at them, ive no idea why.
    just gotta keep fighting the good fight.
    and drinking whiskey
    or beer
    or both.

  10. Well Adam , I am sure you didn’t expect this blog to resonate with so many ? The fact that it has struck a cord suggests to me that we are inadequately educated and are ill informed for the task in hand. I think we are deluded and perhaps seduced initially to think that most people want to ‘get better’ , I know I was . Many enter physiotherapy with the trajectory of the ‘common sense’ approach to injury/ pain resolution -perhaps based on their own experiences in the sporting world or recovery from injury perhaps . In reality, particularly in MSK settings we are faced with the complexity of pain behaviour , ill defined suffering and chronic inter related stress disorders. Working with a medical education welded to a dualistic model we are often ill prepared for what is an increasing reality which education should prepare students to better cope with. I studied Maitland when in fact its more useful to study Ekman https://www.paulekman.com/wp-content/uploads/2013/07/Facial-Expression-Of-Emotion1.pdf or look at the work of this guy ..https://www.amazon.co.uk/Whiplash-Useful-Illnesses-Andrew-Malleson/dp/0773529942….
    General outpatients is often a respite centre for GP patients who get the half hour to 45 minutes of attention rather than the 5minutes at the initial visit and the problem with being an open caring soul is that people off load and it happens all the time ! Managers in NHS settings should support staff and recognise the toll this takes and education should recognise and discuss topics such as somatisation disorders and the like rather than suggest that we can understand people via neurophysiology (which I used to think was the case…..) . Explaining pain to people doesn’t cut it either as many are just not on the page…pre contemplative would the jargonistic term perhaps…Its obviously not like this all the time otherwise I wouldn’t do the job but burnout is seldom a result of not knowing enough, its not knowing enough about the effects interacting with others has when you are not on top form yourself ….
    Do you cover this kind of stuff on your shoulder courses as even Cyriax mentions the shoulder as an emotional area ?!

    • Thanks for your insights and comments Ian, it’s much appreciated.

      I sort of touch on the issues of this on my course, but try not to get to bogged down in it as 1) I don’t know much of the literature on it 2) I haven’t many answers/solutions and 3) it’s a bit depressing, I like people to come away from my course energised and raring to try and help someone with a painful shoulder, but I certainly give a nod to the fact we won’t can’t help everyone and that we need to recognise our own yellow flags as well as those of our patients

      And finally as you say the managers and powers that be need to step the fuck up and support all healthcare professionals that have to do this day in day out, more time away and less people to see would help… And whiskey, lots more whiskey

      Cheers again mate

      Adam

  11. I found your blog quite confusing. Again, what is the source of pain? Do people attend therapy to “get healthy?” It would not appear that you know what the motivations of most people are, if they are not yours.

    • I find your comment quite confusing Barrett. I don’t discuss ‘sources’ of pain, or what the motivations of people are? This blog is about my own thoughts feelings around my compassion fatigue!

  12. Fantastic. On so many levels. I think we should start all evaluation visits with “What are the odds of you taking to heart what you will learn today and making positive changes?” Anything above 50% gets a return visit.

    Steve – 22 years into it….and hanging on for dear life.

  13. Thank you Adam for this post, it’s such an important area to be highlighted. I can definitely identity with having burnout at different points in my career. Physiotherapy managers do need to be aware of the pressures on staff and the mental and physical health implications this can have. We spend all day advising patients about this but can often neglect ourselves!
    I would certainly advise exercise/walks/music or whatever people enjoy to switch off and unwind. Personally I make time for non Physio related activity and love when I don’t have that particular hat on! As time has gone on, I’ve realised (despite some horrified looks from certain colleagues) that it’s nothing to be ashamed of!!
    Keep up the great work Adam.

  14. Adam,

    I’ve followed along on Facebook and here. I think you’ve opened a discussion and highlighting an important issue in healthcare generally and of course physical/physiotherapy specifically.

    This is a complicated and emotionally charged issue. I think it’s a pseudo tabu subject. It’s hard for us as professionals to admit, even if we know it, that we only have so much to give, that we have implicit bias, that we can’t help everyone. Further, we don’t talk about it with students nor teach and train them to cope. Others would chastise some for saying they don’t care, or can’t care. We burn out, or become cynical. Educators, researchers, society, administrators ignore (or don’t know). Providers are too involved or too distant. I’ve reflected on whether you need care to be caring: http://ptthinktank.com/do-you-need-to-care-to-be-caring-sympathy-empathy-compassion-and-caring-in-healthcare/. And, these are cognitive and emotional issues.

    And, it spans care settings. I practice in an acute care hospital in a medical ICU (mortality rate of about 15% IN the unit), so these issues are in the forefront (although still at times ignored). ICU nurses have a higher rate of PTSD than Iraqi war veterans:
    https://www.uchealth.org/news/cu-researchers-take-aim-at-ptsd-burnout-in-the-icu
    https://www.ncbi.nlm.nih.gov/pubmed/25362680

    Now, I don’t bring this up to stay one setting is better or harder than another. They are just different. And, they are all challenging. The idealism of helping people who are excited and eager to learn and change their beliefs, as Adam highlighted quite nicely, wears off quite quickly. And, this is regardless of setting. Why? You realize that regardless of setting you are treating people who are distressed, coping with physical limitations and symptoms, and come in with all of their baseline issues or ability to deal with their new circumstances. Whether a high level athlete or a hospitalized, chronically ill individual, their identity, their function, their life has been altered.

    My sense is that often times we underestimate the profound nature of these situations, especially in outpatient orthopaedics. Relatively, it’s not that bad (you just have pain, you can still do X, you’re not in the hospital, etc, not as bad as Bill over there who blew his knee out, etc). It can be easy, maybe too easy, to assume the profound nature of a critical illness or stroke or amputation. The paradox here is that we may underestimate the person’s resilience or ability to cope. But, the paradox at the level of the provider is the habituation to these situations, and the automatic relative comparisons are brains make. “I’ve seen patients like this do better.” OR “It’s not as bad as so so.”

    To regress back on course here, we see people in horrible situations. And we stumble into to these situations as young, novice clinicians without perspective or skills to appropriate conceptualize and cope. And, maybe how we cope, deal, and conceptualize over time, the skills we develop are not ideal. Do we navigate appropriately?

    This can affect us, our life, and our connections. I ponder aloud if such under recognized effects (burn out, cynicism, relative comparisons, etc) are one of the contributions to patients dissatisfaction with the healthcare system and experience. It’s undoubtedly one of the factors contributing to the struggles of healthcare professionals. And, that contributes to our ability, especially as therapists, to provide high level care. This may affect outcomes. It’s like a dark, sick feedback loop.

    Sorry for the diatribe, but thank you sincerely for your contribution and being willing to discuss difficult, complicated issues.

    • Hey Kyle

      Thanks again for your contribution and comments here! I agree it is often seen as a taboo subject that many think we shouldn’t discuss or highlight for fear of alienating or upsetting the public or patients for admitting that healthcare professionals are human and not perfect.

      We need to recognise those who are suffering and offer support and assistance not chastise or ridicule

      Cheers

      Adam

  15. Another great read Adam and a topic every single HCP will be able to relate to. You are right, we need to be realistic and comfortable with the fact that we aren’t going to be able to help everyone due to many of the factors you raised. The sooner we could realise that in an episode of care the better as these pts are the one’s who can drain every ounce of energy from us. BUT, we care, and mostly know we can ‘help’ them and it’s why we all put our hearts and souls into every consultation. We know a great day can quickly turn into your worst day just by that 1 pt. We feel their distress and it can be exhausting. Like you say, impt we take care of ourselves and I hope employers read this blog and ensure they look after their staff. Paula.

  16. Thanks for this great article on an often neglected topic. Awhile back i heard a fellow clinician say “Never do for your clients more than they are willing to do for themselves” which I think is more eloquent way of saying “give as much of fuck as your clients do”. It’s a philosophy I’ve adopted to help mitigate professional burnout.

  17. Hi Adam – just wondering who you’ve written this post for – your patients, other heath professionals or the general public??

  18. Thanks for your post Adam. As always, I have enjoyed reading it even if I don’t always agree 100%!! After 18 years of practicing, for me its not a case of caring less, but of being much more realistic in my own ability to help people and, more importantly, not taking it personally when I don’t!! Sometimes its biology limiting improvement, but more often than not its the clients motivation and adherence limiting them, so no reflection on me!!!

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