Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

The Messy

“We often jump to reassure, fix, and plan. If we can be still for a moment, we can remain present and let compassion guide our actions.”


Caring for children in the pediatric ED is both rewarding and exhausting. Cultivating compassion for patients and ourselves can help to sustain our practice and our well-being.

One late night, I sat in the middle of the pediatric intensive care unit with my supervising fellow and the hospital chaplain. A teenager we’d been caring for had just chosen to be decannulated and allowed to die. She was 16 and had a rare neuromuscular disease that had progressed to the point that she couldn’t breathe without a ventilator. More devastatingly, she could no longer paint or draw.


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


I’ve been advised on how to tend to the hardship, pain, and trauma experienced by the humans we care for. Well-meaning mentors have warned me to keep an emotional distance from my patients. Burnout experts warn of “compassion fatigue.” Even the language we subconsciously revert to in the ED urges separation from human suffering—we care for “the broken arm in room 12” and “the non-accidental trauma in 15.”


The ingrained Western cultural viewpoint of scarcity—we can never have enough, know enough, be enough—creates a feeling that compassion is finite. A different perspective is that our capacity for compassion is endless—that we can hold and attend to both the joy and the pain of our work. That we can find meaning in and be transformed by the suffering we witness. This begins with recognizing the limitations of empathy.


Compassion versus empathy

In a study of a brain using EEG and MRI, a team of social neuroscientists examined the difference between empathy and compassion. In this experiment the French Buddhist monk, Matteau Ricard, was asked to listen to recorded sounds of a woman screaming with the instruction to feel her distress but do nothing more. The pain centers of his brain activated 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 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.


Ricard also wrote 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— the manifest and latent causes of it—in order to effectively help and empower. Compassion calls us to act, to engage with our patients.


Self-care as a sacred act

Cultivating compassion and sustaining it through the demands of our profession takes effort. Caring for yourself while caring for others should be a daily practice held with the same reverence as doctoring. The practice looks different for each person. Here are a few key components in mind:


1. Pause frequently.

Intentionally make space for rest, recovery, and stillness. At work, this could be pausing and reflecting after losing a patient. At home, this could be simply enjoying a moment of solitude instead of scrolling on your phone.


2. 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 learns her five-year-old has leukemia, it’s easy to do what Dr. Brene Brown calls “overfunction.” Rather than recognize how our emotions are impacting us, we jump to reassure, fix, and plan. If I sit and say to myself, “I’m feeling fear and anger,” I can remain present and let compassion guide my actions.


3. “If your compassion does not include yourself, it is incomplete.” — Jack Kornfield 

When struggling to help a patient, try a practice recommended by Dr. Kristen Neff. To begin, simply notice your breathing. With every inhale think about breathing in compassion for yourself, and with every exhale breathe out compassion for your patient. Even this small departure from focusing on others makes some of us feel uncomfortable and as if we’re our abandoning our role as caretakers. But it can help you move from simply trying to fix to feeling love for another. And love, far from sentimentality, is the force that undergirds the most important and transformative moments for humankind.