I’ve Had Enough!

The student presented the case in the precepting room: Mrs Palmer’s daughter brought her mother in because Mrs Palmer had stopped taking her diabetes medicine. Her social history hooked me. An 82-year-old Jamaican woman visiting Miami, Mrs Palmer had been staying with her daughter for the past 6 months. Mrs Palmer’s husband had had a stroke 15 years before, leaving him bedridden and paralyzed. Mrs Palmer had stayed with him for 12 years, literally never leaving his side; she even slept in the same room. Then, 3 years ago, she had become exhausted and began visiting family members living outside of Jamaica. Prior to his stroke, she and Mr Palmer frequently fed people who were “down on their luck.” Those visitors still came to her door, but she could no longer deal with seeing them. She opened the door, said “Come on into the kitchen and get what you need,” left the kitchen and waited in another room until the hungry visitors left. She stopped her medicines around that time. As the student and I discussed her case, compassion fatigue jumped out at me. The student had never heard of the term and I encouraged him to read about it.

We went in to see Mrs Palmer. I savored her Jamaican cadence. Like gentle, undulating ocean waves, her voice rhythmically outlined the changes in her life after her husband’s stroke. In the same soothing tempo, her daughter, Ms Whyte, wondered what had happened to her selfless mother. She was distraught and could not understand the radical about-face in her mother’s life, from never leaving her husband’s side to finding his side intolerable, from eagerly feeding the hungry to barely being able to endure their presence.

When I outlined the idea of compassion fatigue, Mrs Palmer said excitedly, “Yes that’s what I’ve been telling everybody! I’ve had enough!” Her daughter looked at Mrs Palmer, agape, then turned to me, “You mean this is something that happens?”

“Yes, and it’s something we can work on.” Her daughter seemed so relieved that her mother was not lost to her but, rather, was burnt out in terms of caregiving. We talked about how we cannot care for others if we are not caring for ourselves.

“How can we help you refill your spiritual self?” I asked Mrs Palmer.

Mrs Palmer spoke about the meaning of God in her life, while also sharing she could no longer tolerate church because there were too many people and noises. Quiet and nature were restorative to her.

The visit was a long one, and I could see the student struggling to stay still as he knew we had other patients waiting. Yet, it was a necessary conversation to have. Mrs Palmer and her daughter left with a little bit of hope, taking home the idea that Mrs Palmer wasn’t irrevocably lost or broken.

Seeing Mrs Palmer brought up questions and memories for me. I thought about my own compassion fatigue. Growing up, I had taken care of so many in my life, including adults. Of course, I became a professional caregiver who worked in a county safety net health system. I remembered well that feeling of having had enough, just as Mrs Palmer had desperately voiced, when the system cut costs by laying off dieticians, social workers, nurses, dentists, and janitorial staff, but continued to ask that care not suffer or change at all. Those vital team members’ absences led me to try to perform their roles in addition to my own. The underserved patients at the clinic required even more patient education, more creativity with medication costs, and more streamlining to reduce specialty, lab, and imaging fees. When I got home from clinic during that time, I wanted to do nothing. I reflected on the medical training that taught me to put patients’ needs before mine. Yet, I learned experientially that if I am always putting others’ needs before mine, in time, I will have nothing left to give. In fact, only by attending to my needs could I care for patients more effectively, creatively, and lovingly.

In training students, I hope to discontinue this flawed belief that being a good physician requires always putting others’ needs before one’s own. As clerkship director, I tailored the student assessment used by clinical faculty to exclude this unrealistic expectation. I have learned firsthand that this skewed value is a recipe for compassion fatigue. When at work, patients must receive our undivided, caring attention. Yet, even when overbooked and overburdened, I must take care for myself and my basic needs. I have learned that empty personal spiritual and self-care accounts inhibit my ability to provide compassionate, humanistic care. Self-care also means leaving at a reasonable time, even when there was work left to be done and understanding that I cannot fix or carry a broken system.

Who do I want taking care of me when I am a patient? Do I want an automaton? Or a real person who, by prioritizing self-care, is whole and healthy? Where is the humanity in burnout? Where is the beauty, joy, awe, and mystery of life when one is working at one hundred miles per hour without regular rest stops?

Seeing Mrs Palmer reminded me that I needed to care for myself in addition to encouraging her to fill her self-care account. I went home after clinic and had a lovely dinner with my husband, a new friend and her husband and wrote about my day, choosing recovery of self by making a large deposit into my own self-care account, recharged and able to provide excellent care the next day in this challenging health care setting.