Compassion Fatigue

By Julia M. Huber, MD, FACEP

Compassion fatigue (CF) is also known as vicarious traumatization (VT). In the Compassion Fatigue Workbook, Francoise Mathieu states, “Compassion fatigue refers to the profound emotional and physical exhaustion that helping professionals and caregivers can develop over the course of their career as helpers. It is a gradual erosion of all the things that keep us connected to others in our caregiver role: our empathy, our hope, and of course our compassion—not only for others but also for ourselves.”

It is “the cost of caring for others in emotional pain,” is an “occupational hazard,” and a “cumulative process.” Some providers lose all empathy during this process, and report feeling a fundamental shift in their worldview.


  • Abusing drugs, alcohol or food
  • Anger
  • Blaming
  • Chronic lateness
  • Depression
  • Diminished sense of personal accomplishment
  • Exhaustion (physical or emotional)
  • Frequent headaches
  • Gastrointestinal complaints
  • High self-expectations
  • Hopelessness
  • Hypertension
  • Inability to maintain balance of empathy and objectivity
  • Increased irritability
  • Less ability to feel joy
  • Low self-esteem
  • Sleep disturbances
  • "Workaholism”

(source: John Henry Pfifferling, PhD)

As emergency physicians, we are all at risk for compassion fatigue. Consider the following risk factors for compassion fatigue, taken from Martha Teater and John Ludgate’s workbook, Overcoming Compassion Fatigue: A Practical Resilience Workbook -

  • The secondary trauma was an act of human cruelty
  • Longer exposure to the trauma of others
  • Multiple stressors in the caregiver’s personal life coinciding with the secondary trauma
  • A personal trauma history
  • Lack of social support
  • Habitual self-negativity
  • Working in isolation

Tools and Solutions

Personal level
Raise your virtual hand if you “already know” you need to sleep more, eat more nutritious meals, and balance your life by being mindful and practicing meditation. How do you bridge the gap between knowing about self-care and getting into action?

Here is a suggested series of exercises, rather than feeling like you have to drink kale smoothies -

  • Write it down. Look at the lists above every day for the next few weeks. Which symptoms are the most prevalent? Are you experiencing them at work, or just following a shift? Do you have any of the risk factors that contribute to your loss of empathy? Make a note of how long it takes you to bounce back from a shift, and which symptoms bother you the most. You may start seeing other patterns or symptoms of stress; add these on so you can flag yourself more quickly.
  • After looking at your personal symptomatology, develop your own personalized “self-care” list, and prioritize them. Base this list not on what you think everyone would recommend you do, but on what specifically works for you. My personal list includes ample amounts of chocolate and reading great literature, even if it means sleeping less. As I said, this list is for you! 
  • Develop a personal meter, such as a scale from 1-10, and look for patterns. Which symptoms are the most pernicious? If you were to eliminate just one or two or them, what would your life look like and BY WHEN? What about this is important to you? What do you risk losing if you decide to continue with the status quo? What would it take you to go up just one notch on your own compassion satisfaction score?
  • Make a decision to look for support. Do you need professional help in order to re-find meaning in your job and life, and regain a sense of compassion for your patients and for yourself? Do you need to see a psychiatrist to treat depression or addiction? If your family or friends are expressing concern, that should be enough of an indicator to get professional help. Are you a healthy person wishing to seek change through professional coaching, or is it time to form a peer support group? 
  • Debriefing. There are two kinds of debriefings, formal and informal. The formal type is scheduled, and is referred to as Critical Incident Stress Debriefing, and you may refer to your Human Resources Department for further information on how your institution facilitates this process. The more informal types of debriefing happen on the fly - at change of shift, in the doctors’ lounge, the holiday party or even the kids’ soccer field. Although this can be therapeutic for the person sharing, we can at times “slime” the recipient by not asking them permission to disclose sometimes graphic information, which can then lead to them in turn suffering from vicarious trauma, as well. Mathieu recommends the four-step process of Low-Impact Disclosure (LID), which involves increased self-awareness of when and how you spontaneously debrief (or slime!) others; providing the recipient with fair warning of what you are doing; obtaining the recipient’s consent to engage at that level, then limiting the amount of graphic information provided. 

Organizational/systemic approach

  • What managers can do? (adapted from Teater and Ludgate, Overcoming Compassion Fatigue) Regularly check in with staff rather than waiting for them to approach you, engage in your own self-care program, strive to stay positive, and avoid stigmatizing staff who are suffering from CF or other stress-related issues. 
  • What ACEP is doing? The Well-Being Committee is updating the wellness text on the ACEP website and working with the IT staff to enhance better visibility and access to this information. The Emergency Medicine Wellness Week started in 2016 strives to highlight the organization’s commitment to well-being. In the next few years, we hope to create more instructional tools for individuals, as well as groups of physicians across all career phases. 
  • What residencies can do? Provide a lexicon of wellness early on in residency, as well as means identification of issues such as compassion fatigue and burnout; provide workshops that facilitate the creation of a personal self-care “toolbox” to turn to both during and after residency in order to support a continued commitment to personal well-being. 

As emergency physicians, we have made a conscious choice to step in and care for people and also face challenging and sometimes painful circumstances. It is a privilege and at times, can be a burden. Writer and internist Dr. Danielle Orfi, in her book What Doctors Feel sums this up best:

“For physicians, sadness is part of the job … Integrating sadness while still being able to function and give of yourself is necessarily a work in progress. It is something akin to two coils spinning. The coil of sadness never stops - there is always awareness that your patients are suffering and the memory of the patients you’ve lost. The other coil is the engine of what you are giving to your new patients, the investment in their lives and health. Nobody desires grief in one’s life, yet wise and experienced clinicians will tell you that they’d never want that coil to disappear. It keeps alive a necessary appreciation of medicine, of what it means to have the privilege of entering other people’s lives.”

Bibliography/Helpful Links/Additional Resources
A detailed research bibliography that goes up to 2010, but very extensive background; this website also has the Professional Quality of Life or ProQOL test for compassion fatigue, burnout, and compassion satisfaction.
Self-care tips that are helpful; consider sharing them with your group or other colleagues.
Secondary trauma in medical students
AAFP article on saying “no” effectively.

Mathieu, Francoise. (2012). The Compassion Fatigue Workbook: Creative Tools for Transforming Compassion Fatigue and Vicarious Traumatization. New York: Routledge, 2012.

Orfi, M.D., Danielle. What Doctors Feel: How Emotions Affect the Practice of Medicine Beacon Press, Boston, 2013.

Pfifferling, PhD, John Henry and Kay Gilley, M.S. “Overcoming Compassion Fatigue”. Fam Pract Manag. 2000 Apr;7(4):39-44.

Stamm, B.H. The ProQOL manual: The professional quality of life scale: Compassion fatigue/secondary trauma scale. Baltimore: Sidran Press, 2005. An updated 2010 version is available now online: Click on “manual” for your free download.

Teater, Martha, and John Ludgate, PhD: Overcoming Compassion Fatigue A Practical Resilience Workbook. PESI Publishing and Media, 2012.

Van Dermoot Lipsky, L., and Burk, C. Trauma Stewardship: An Everyday Guide in Caring for Self While Caring for Others. San Francisco: Berrett Koehler, 2009.

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