Becky Blake and Matthew J. Butler, "Avoiding Empathy Fatigue: What CNF Educators Can Learn from an Oncologist" (Assay 11.2)

ASSAY: A JOURNAL OF NONFICTION STUDIES
11.2

Becky Blake and Matthew J. Butler

Avoiding Empathy Fatigue:
What CNF Educators Can Learn from an Oncologist

Becky Blake, MFA (CNF Instructor at the University of Toronto’s School of Continuing Studies)

Matthew J. Butler, MD (Assistant Professor and Hematologist-Oncologist at Mays Cancer Center, UT Health San Antonio)

Introduction

At the end of last semester, I (Becky) was feeling emotionally fatigued. A significant portion of the student assignments from my two creative nonfiction classes were, as they often are, essays exploring a difficult personal story, such as an experience of death, illness, or abuse. These assignments felt less moving to me than usual, as though their poignancy was being diluted by the many similar essays I’ve read over the past decade. Feeling guilty about my failure to fully connect with the personal stories I’d been entrusted with, I was working very slowly.

Emotional fatigue is common in “high-touch” professions such as teaching, coaching, and healthcare. My husband (Matthew) happens to be an oncologist, and he encounters situations requiring empathy on a daily basis. It occurred to me that he might have developed some strategies that could be relevant to my own work, so I decided to ask him. Together, we’ve tried to recapture our conversation below.

BECKY: I’ve been thinking about the intersections that exist between the types of work we do. We both witness hard moments of a person’s life and must respond with empathy. We both need to maintain enough detachment to be able to offer clear and helpful professional guidance. And we need to do this repeatedly without burning out.

So first off: how important is empathy in your work? Do you feel like it’s essential or is it more of a liability?

MATTHEW: Empathy is central to what I do in a number of ways. It allows me to stay focused as people recount symptoms that might otherwise become tedious. It’s also a key ingredient in building a relationship of trust with a patient and a family, which is in turn necessary to make hard decisions together, as well as being therapeutic in its own right. Treatment really does work better if you believe in it, and it’s hard to believe in a treatment unless you also believe in the person giving it to you.

Of course, it’s also my job to give objective assessments and recommendations based on science and data. Some healthcare workers think of this responsibility as technical, and worry that emotion can cloud judgment, especially when the truth is unpleasant. In my experience, the opposite is true: the moments when my opinions are most honest and my recommendations are most well-considered are precisely those when I am most emotionally invested, because every part of my brain—analytical and intuitive—can engage simultaneously.

BECKY: I love that idea: that empathy actually elevates your ability to make analytical decisions. And I think that’s why I feel guilty about not always having the emotional stamina to deeply empathize with every student’s story. There are so many tough ones, and some difficult themes come up again and again. In your clinic, you see the same sorts of cases over and over. How do you keep yourself from becoming desensitized to them? (If you do.)

MATTHEW: The essence of science is generalizability. We look for patterns, categories, sameness. But sameness is boring. When you deal with a lot of cases with similar features and recurrent themes, they can start to blur together in your mind. That’s dangerous, because if the wrong fact crosses over from one case to the next, it can lead to a bad decision. The only way to keep each patient separate is to make each one a story—to latch on to a few oddly specific details that make this one human being unique within the sea of humanity, and this one instance of disease subtly different from all the others.

BECKY: Building a story around each student happens naturally in my work, because my relationships with students actually arise from the stories they share with me. But the more detailed my picture of the person is, the more I connect with them, and the more emotional energy it takes to respond when they share something harrowing. You once told me that some days it seems like cancer only strikes the nicest people. What did you mean by that?

MATTHEW: That’s just a bit of dark humor among oncologists, but it reveals a truth about us as humans: the more closely we relate to someone, the more aware we become of their suffering. Of course, cancer doesn’t discriminate, and every misfortune is sad in its own way. I’ve treated thousands of patients, and I would like to think that I have some memory of each one. But certain cases have some feature that gives them extra emotional resonance – something about the person or situation that is especially sympathetic or relatable – and those are the ones that stick in my mind. That’s true for the happy cases – the cures, the remissions, the families who reach a state of acceptance and peace. As treatments improve, good outcomes only get more common, and the joy that these bring can be unforgettable. But of course, it’s the tragedies that can be truly haunting.

BECKY: Yes. I find it especially hard to know how much to engage with the most tragic of the stories I receive. Did they teach you anything in medical school about how much empathy you should show or express to patients who are facing the worst outcomes?

MATTHEW: My residency program employed actors to give us practice in having difficult conversations. There are also systems and mnemonics that have been created to help structure these conversations and to teach healthcare workers to perform empathy better. But empathy is inherently hard to teach, because it is not a performance—not the words you say, but the feelings you feel. If I can find that place of empathy, the words just sort of come out organically. When I can’t, the words ring hollow. Empathy is not something that can be summoned at will; some days you feel it, and other days you feel it less. But it always comes back. Empathy is a practice and, for me, it seems to come more naturally over time.

BECKY: When you do manage to access that “place of empathy,” how do you switch gears to move into the medical guidance portion of an appointment? Is there an amount of time you spend on the personal before moving on to the clinical?

MATTHEW: When this works well—when I’m at my best—the facts and feelings are woven together so seamlessly that it’s hard to tell where one stops and the other starts. I think generally I try to lead with empathy, to open a channel of connection. But less is more. It’s better to briefly acknowledge someone’s pain or fear, to make it clear that I’m aware of it before moving on to business, rather than trying to make an effusive performance of empathy that I don’t feel, and that can come across as insincere.

BECKY: I think that’s a good strategy for providing feedback on writing too: to begin by acknowledging the difficult emotions at play, and then move on to providing constructive comments, which is my primary job.

MATTHEW: Right. I try to form a connection with each patient, as best I can. But it’s my job to give truthful information and sound advice to everyone.

BECKY: You mentioned you see thousands of patients. And I’ve worked with hundreds of students. If we manage to make a difference in someone’s life, then it’s likely they will remember us vividly, while we might barely remember them at all. Sometimes I struggle with how to think about that disparity.

MATTHEW: That dynamic exists in any specialized profession; we’re part of many asymmetric relationships. People seek our help because they find themselves in a realm which is extraordinary and strange and possibly terrifying. But for those of us who live in that realm, and have grown accustomed to its peculiar contours, it’s commonplace—just another day at work. Newcomers to the realm need two things from us. They need to feel seen, that we are paying attention to the unique aspects of their situation. But they also need to know that we’ve seen this kind of thing before, and that they are actually a little less unique than they initially thought. Some people who are faced with a cancer diagnosis feel enraged at having been singled out by the universe, as if this is the cruelest and most unfair thing that has happened to anyone, ever. The reality that cancer is something they share with countless others, something that people go through every day, can be hard to hear at first, because it seems to diminish their own experience. But ultimately, the knowledge that one is not alone can only be comforting.

BECKY: That’s interesting to consider. I usually focus on ways to make sure a student knows that I am paying attention to their unique story. But perhaps it might be a relief to them and to me if I allowed myself to also acknowledge that I’ve heard many similar stories—that others have lived and written about similar things. That they’re not alone.

MATTHEW: Yes. I do think it’s important to recognize that beneath the stories that make each of us unique, there are lots of commonalities that bind us together. All of us suffer. All of us will die. Every moment of our lives is fleeting and precious, whether you’re someone who has a lot of moments to look forward to, or someone with fewer. Reminding my patient—and myself—of these universal human truths lets me connect with the details of their situation without being overwhelmed by it.

BECKY: Overwhelm is one of the symptoms of emotional fatigue, along with anxiety, irritability, and feelings of powerlessness or ineffectiveness. When you recognize these symptoms creeping in, how do you work to limit them? Do you have any self-care tips that might be more widely applicable?

MATTHEW: Doctors are notoriously bad at taking care of ourselves, and we spend a lot of time coping with and masking burnout, rather than truly resolving it. But I have two observations. First, the pathway to relieve burdens of the mind is through the body. I know of no affliction—medical, mental, or spiritual—that is not relieved in some way through physical exercise. Listen to your breathing, feel the comforting beat of your heart, move through the world. Second, empathy can never flow in only one direction. For every human being, no matter how strong we are, how solitary, how introverted, how self-sufficient, each of us needs support from someone else. Someone who can hear the stories that we carry, or at least the hardest ones, those experiences that cling to us and weigh us down and need to be spoken to be set free. Support like this comes from many places: family, close friends, colleagues, a spouse or lover, even a pet. But if you spend your time caring for others, someone has to care for you.

BECKY: Thank you. I feel cared for by this conversation.

Conclusion

It is natural to feel occasional bouts of emotional fatigue when responding to a high volume of difficult stories from students. But to avoid this fatigue turning into burnout, it may be helpful to remember: that empathy is a practice that grows and deepens over time; that although each student’s story is unique, it’s also okay to acknowledge the universal human experiences that underpin the personal ones; and that if you want to respond effectively and empathetically to a student’s story, then someone has to be listening to your story too.

Click here to download a printable PDF with Works Cited.

Becky Blake is a creative nonfiction instructor at the University of Toronto's School of Continuing Studies. Her essays have appeared in publications such as Brevity, The New Quarterly, PRISM, and The Humber Literary Review. She is the author of the novel Proof I Was Here and the monthly newsletter Truly Important, which explores the many benefits of writing true stories. Find her at: www.beckyblake.ca or trulyimportant.substack.com.

Matthew J. Butler has degrees in philosophy (University of Toronto), informatics (University of Edinburgh), and medicine (Saba University). He is an Assistant Professor of Medicine at UT Health in San Antonio, where he teaches, conducts clinical research, and practices hematology and oncology at the Mays Cancer Center. He specializes in treating multiple myeloma and other blood cancers.

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