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Burnout, empathy and their relationships: a qualitative study with residents in General Medicine a
a
b
Jeanne Picard , Annie Catu-Pinault , Emilie Boujut , Marion c
a
Botella , Philippe Jaury & Franck Zenasni
c
a
General Medecine Department, Université Paris Descartes, Sorbonne Paris Cité, Paris, France b
Laboratoire Psychopathologie et Processus de Santé, Institut Universitaire de Psychologie de Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Boulogne-Billancourt, France
Click for updates
c
Laboratoire Adaptation Travail Individu, Institut Universitaire de Psychologie de Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris cité-Sorbonne, 71 avenue Edouard Vaillant, 92100 Boulogne-Billancourt, France Published online: 15 Jun 2015.
To cite this article: Jeanne Picard, Annie Catu-Pinault, Emilie Boujut, Marion Botella, Philippe Jaury & Franck Zenasni (2015): Burnout, empathy and their relationships: a qualitative study with residents in General Medicine, Psychology, Health & Medicine, DOI: 10.1080/13548506.2015.1054407 To link to this article: http://dx.doi.org/10.1080/13548506.2015.1054407
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This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Psychology, Health & Medicine, 2015 http://dx.doi.org/10.1080/13548506.2015.1054407
Burnout, empathy and their relationships: a qualitative study with residents in General Medicine Jeanne Picarda, Annie Catu-Pinaulta, Emilie Boujutb, Marion Botellac, Philippe Jaurya and Franck Zenasnic* a
General Medecine Department, Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Laboratoire Psychopathologie et Processus de Santé, Institut Universitaire de Psychologie de Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Boulogne-Billancourt, France; c Laboratoire Adaptation Travail Individu, Institut Universitaire de Psychologie de Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris cité-Sorbonne, 71 avenue Edouard Vaillant, 92100 Boulogne-Billancourt, France
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b
(Received 15 January 2015; accepted 19 May 2015) Some studies have shown that burnout may have a negative impact on clinical empathy during internship. However, clinical empathy may also be a protective factor, preventing residents from experiencing burnout. Although several quantitative studies have been conducted to examine these relationships between burnout and empathy, no qualitative studies have been carried out. To examine how residents in general practice evaluate the link between burnout and empathy, 24 of them participated in a semistructured interview. A thematic analysis was carried out to examine residents’ discourses and answers to closed questions. The results indicated that residents thought that empathy and burnout were clearly related in different ways. They identified five types of relationship: regulation strategy, empathy as protection, psychological balance/imbalance, fatigue and moderating factors. Keywords: burnout; empathy; residents; compassion
Clinical empathy appears to be a non-technical core competence in primary care (Halpern, 2012; Hojat et al., 2002), and is a quality widely expected by patients. Studies have shown that it favors physician–patient relationships and significantly reduces medical errors (Heje, Vedsted, Sokolowski, & Olesen, 2008; Verheul, Sanders, & Bensing, 2010). Despite its importance, clinical empathy is rarely performed or developed. It could even decrease during medical school and residency (Neumann et al., 2011). Several factors may explain this dulling of empathic skills during internship, one of which is the well-being of residents, which is directly related to their empathic potential. Mazurkiewicz, Korenstein, Fallar, and Ripp (2012) explained that high levels of burnout may be observed during medical school and this has a significant impact on residents’ health and, potentially, on their non-technical skills. Several quantitative studies have tested the relationships between burnout and empathy, concluding that burnout hinders the expression of empathy. Thomas et al. (2007) observed that low well-being was related to lower medical student empathy. Brazeau, *Corresponding author. Email: [email protected] © 2015 Taylor & Francis
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Schroeder, Rovi, and Boyd (2010) reported that the higher the level of burnout, the lower the self-reported empathy of general physicians. Similarly, Zenasni, Boujut, Buffel du Vaure et al. (2012) observed that the higher the level of burnout of general practitioners, the lower their empathy. Although these studies have confirmed a significant relationship between burnout and empathy, they have not identified the factors and/or processes underlying these associations. Recent research has begun to address this issue. Lamothe, Boujut, Zenasni, and Sultan (2014) detailed the nature of these relationships by taking into account two distinct components of empathy: perspective concern and perspectivetaking. They showed that while low perspective-taking is a risk factor for burnout, high levels of perspective-taking and perspective concerns may prevent a physician from being in burnout. These results are in line with those of Zenasni, Boujut, Woerner, and Sultan (2012) who proposed that burnout and empathy might be interrelated in three different ways. First, burnout and empathy are related because the physician’s burnout impacts their empathic potential. From this perspective, burnout, induced by organizational or dispositional causes, will reduce empathy, at least in part, due to its depersonalization effect. Health providers in burnout will tend to prefer solutions of psychological withdrawal (Truchot, Roncari, & Bantegnie, 2011). Thus, exhausted physicians will be less able to put themselves in the patient’s shoes and to demonstrate empathic listening, and will prefer to protect themselves by keeping the patient at a distance and depersonalizing them. Second, empathy causes burnout due to a greater investment in the pain and emotions of others, leading to exhaustion. A high level of emotional concern may cause ‘compassion fatigue,’ which in turn induces exhaustion and burnout. For Nielsen and Tulinius (2009), compassion fatigue in general practice refers to ‘being exhausted emotionally’ due to frequent difficult patient encounters, associated with the need for high attention and empathic listening. However, this view involves a specific definition of empathy, focusing on affective aspects. One inappropriate consequence of affective empathy is that physicians may become too concerned with the feelings of the patient and thus offer improper compassionate care. Third, the empathic actions of health practitioners may prevent them from experiencing burnout. Halpern (2012) suggested that a well-proportioned empathy might enhance job satisfaction and thus reduce the risk of burnout: being empathic implies being aware of one’s own negative emotions, practicing self-reflection and accepting negative feedback, which are resources that can be used against stress and burnout. The results of Lamothe et al. (2014) confirmed this third perspective by showing that empathy is associated with less emotional distress. Based on the works of Zwack and Schweitzer (2013), they verified the idea that good interactions with patients will promote patient gratitude, which in turn is a source of strength and satisfaction for the physician. Although recent quantitative studies may help to infer and confirm, at least in part, these three types of relationship (Lamothe et al., 2014), qualitative studies are also helpful since they can show how burnout and empathy interact and give rise to these three potential effects. With this objective, the present research aims to explore the potential factors and processes underlying burnout–empathy relationships, by interviewing residents in general practice.
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Methods Participants Residents in general practice were recruited from Parisian universities. They were considered eligible if they were aged from 20 to 35 years, registered on a specialized degree course (general medicine) and fluent in spoken French. Twenty-four residents (12 men, 12 women) aged from 25 to 30 years (mean age = 27.3 years) were recruited. Two refused to participate without giving any specific reason. Eight were in their first year of residency, three in their second year, twelve in their third year and one in their fourth year.
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Material Based on a literature review and experience feedback from residents, we developed a semi-structured interview guide. In the first part of the interview, residents were asked to describe their current internship. Then, they answered open-ended questions concerning (1) the representations and definitions of empathy (‘What is empathy for you? In general? In your medical practice?’), (2) the importance and the impact of empathy for their medical practice, (3) the way empathy may improve the care of patients, (4) the impact of the use of empathy on their own health and (5) the potential relationships between empathy and burnout. The second part of the interview included three questions related to the three hypotheses linking empathy and burnout: ‘Do you agree that (1) burnout decreases empathy due to depersonalization?’ (2) empathy favors burnout because of compassion fatigue?’ and (3) empathy prevents one from being in burnout?’ For each hypothesis, residents were asked to develop their answers. Procedure Residents were contacted by mail or by phone during their internship. When they agreed to participate, they met the interviewer in a quiet room in a face-to-face position. The demographic data of the participants were collected before the start of the interview. All the interviews were recorded with the oral consent of the participants. Results Empathy and burnout: open interviews A thematic analysis was conducted to identify how residents related empathy to burnout. Five main topics were extracted: empathy as protection, regulation strategy, psychological balance, fatigue impact and moderating factors (Table 1). Regarding protective empathy (Theme 1), 10 residents considered empathy useful for the practice of medicine and necessary for their own satisfaction and achievement in their work: ‘It makes me feel good to have empathy for people, it’s never hurt me, I’ve always felt more satisfied when I’ve thought I’ve succeeded in understanding someone, in sharing their feelings a little bit.’ Although empathy was beneficial for care, most residents stated that its use/practice had a direct impact on their emotional states and might create fatigue (Theme 2), which affected their interactions: ‘There are some days when listening to patients is tiring and then we are no longer sensitive to their problems.’; ‘I think that an exhausted physician can’t think of others and take care of them.’ Thus, because empathy may have a damaging impact, some residents suggested that it
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Table 1.
Thematic matrix based on the resident interviews.
Topic
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Empathy is protective Workload affects empathy Regulation strategy Psychological balance/imbalance Moderating factors Identification with patients Knowledge/abilities relative to empathy Stress factors/organizational constraints/gratitude
Number of residents mentioning the topic (men/women) 10 (7/3) 5 (3/2) 12 (4/8) 9 (4/5) 14 (10/4) 5 (3/2) 4 (3/1) 5 (4/1)
must be carefully regulated in order to stay applicable and to avoid exhaustion or burnout (Theme 3): ‘You mustn’t get too deeply involved because that’s exhausting and afterwards, well what can I say, you have to stand back because it weighs you down.’; ‘You have to learn to control this empathy.’ Several residents pointed out the need to maintain a distance between themselves and their patient and to find a balanced attitude (Theme 4). Otherwise, empathy may create too much compassion, which in turn may create emotional difficulties: ‘And if there’s too much empathy, I know that that could overwhelm me.’; ‘In my opinion, too much empathy would not be beneficial, […] well, you have to find the right path between the two.’ This equilibrium, according to some residents, seems to depend on specific factors, which we call moderators (Theme 5) since they moderate the impact of empathy on burnout or the impact of burnout on empathy. Three kinds of moderator were mentioned by residents. They refer to (1) the identification with patients, (2) knowledge/abilities relative to empathy (3) and stress factors (see Table 1). The most frequent moderator is the ‘identification’ with a patient. Some residents suggested that empathy favored compassion then burnout when a patient reminded them of a specific important person (a parent, a friend, etc.) or even themselves: ‘There are illnesses which remind me of close friends or relatives, or make me think about myself, so that means I’ll be more empathic.’ Some moderators refer to the ‘savoir faire’ of residents in relation to empathy: knowledge, learning, abilities or experiences about empathy may prevent residents from becoming exhausted: ‘If you know how to manage a consultation, you waste less time, you don’t go back over other things, and you can be more empathic and have less burnout.’ Finally, the last kind of moderator refers to the organizational or contextual situation, which may favor stress and then condition the change of empathy into burnout. These moderators refer to workload, stress factors or lack of gratitude from the patient: ‘Maybe some people are too empathic, but if their workload was adapted, […] they wouldn’t be depressed or have burnout and so on. […] Maybe someone is very empathic and has a huge workload, and that’s it!’ Opinions about the three proposals We observed (see Table 2) that a large majority of the interviewed residents (87.5%) agreed with the first proposal indicating that burnout has an impact on empathy.
Psychology, Health & Medicine Table 2.
Resident answers to the three propositions.
Propositions Proposition 1: Burnout impacts empathy due to a depersonalization effect
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Residents agreed (men/women) 21 (12/9)
Explanations • •
•
General loss of interest (n = 3) Loss of interest in patients (n = 13) ○ No interest in patients (n = 7) ○ Being selfcentered (n = 2) ○ Self-protection (n = 2) ○ Objectification of patients (n = 2) Fatigue (n = 2)
Proposition 2: Empathy favors burnout because of compassion fatigue
12 (3/9)
• •
Overload (n = 8) Lack of coping strategy (n = 2)
Proposition 3: Empathy prevents burnout because of satisfaction at work
16 (8/8)
•
Feeling of helping (n = 5) Gratitude/feedback from patients (n = 3) Satisfaction with the work done (n = 2) Relational interest of the job (n = 2)
• • •
Three of them suggested that this loss of interest was general: ‘When you are in that phase, you’re no longer open to anything.’ Thirteen specified that this loss of interest was specific to relationships with patients. Thus, seven residents stated a loss of interest in patients: ‘I only wanted to do the technical aspect and I didn’t feel like talking to people.’ Two residents put forward the idea that stepping back was a kind of self-protection: ‘If you are in burnout you are already weighed down by what’s happening to you and you need to protect yourself, you can’t feel other people’s pain as well.’ Two residents indicated that this withdrawal was associated with an objectification of patients: ‘I think it’s true because you don’t have too much empathy any more when you’re in burnout, you see the patients more as a number and you try to treat them.’ Finally, supporting the first proposal, two residents suggested that burnout affected empathy due to fatigue: ‘I’m sure that when you’re exhausted, when you’re fed up, when you’re overwhelmed by tiredness and your feelings, it’s hard to have empathy.’ Concerning the second proposal, 50% of the residents thought that empathy favored burnout due to compassion fatigue. Eight of them said that empathy generated burnout by creating an emotional labor and workload: ‘I think that the resident is so filled with emotion that, at some point, it’s only natural that it causes compassion fatigue.’ Two residents suggested that compassion might be due to a lack of coping with the situation:
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If you go further than empathy and it’s no longer just empathy, then there’s a risk of burnout because you’re going to find yourself in situations that you can’t manage, you can’t control your feelings and then you’re at risk of burnout.
Concerning the third proposal, 66.6% of the residents thought that empathy might prevent burnout. They considered empathy an important component of job satisfaction. Thus, five residents indicated that feeling that they were helping people increased their satisfaction and even enriched them: ‘Because when you feel that you’ve helped the patient, somehow you’re happy. It’s through empathy and through those you can help that you can fix things a bit.’ This sense of helping was also mentioned by three residents in terms of patient gratitude: ‘They’re people who really like to be thanked and who like to be recognized for the work they do.’ Two residents talked in terms of job satisfaction: ‘I think that empathy can reduce burnout, in fact, because you’re happier with the work that you do.’ Two other residents emphasized the relational interest of their job: ‘I didn’t choose this profession for the technical aspect, it’s really for the contact with people, and so if I’m deprived of that, […], I would be worse off.’ Discussion The aim of the present study was to examine how residents in general practice related empathy and burnout. For this purpose, qualitative research was carried out by conducting semi-structured interviews. The results indicated that residents thought that empathy and burnout were clearly related in different ways. Most residents agreed that burnout impacted empathy due to a depersonalization effect. They frequently described these effects of burnout as the development of a loss of interest, which might be general or specific to resident–patient relationships. Burnout favored a kind of detachment from the context or from other people. Detachment was expressed in terms of ‘self-centeredness’ or voluntary withdrawal in order to protect themselves. We also observed that empathy might appear as protective or safeguarding for residents. In fact, as suggested by Lamothe et al. (2014), it provided satisfaction at work, particularly when there were feelings of a job well done, of social relationships with patients and of helping, especially when patients expressed some gratitude or gave feedback to residents. In this perspective, empathy appeared mostly as a personal accomplishment at work rather than an emotional labor. However, to a lesser extent and in line with previous theories (Larson & Yao, 2005; Neumann et al., 2011), the practice of empathy may also be considered emotional labor. Half of the interviewed residents agreed with the idea that empathy favored burnout because of compassion fatigue, or even general fatigue. Being empathic or too empathic might provoke overload at work, particularly when residents could not cope with situations, and put limitations on their interactions. This is why some residents mentioned the need for a regulated coping strategy in order to not go too far and lose psychological and relational balance. A last important point observed in the residents’ discourses is that the links between burnout and empathy might depend on specific conditions and/or factors. These moderating factors might be considered triggering variables, which might favor the path from empathy to the presence or absence of burnout or the path from burnout to a lack of empathy. Thus, we observed that identification with patients might be crucial to explain why some residents felt compassion and then risked burnout. Similarly, empathy might become dangerous if it interacted with organizational constraints or other stress factors. On the other hand, acknowledgment by patients, and knowledge and skills in
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clinical empathy seemed to be factors considered helpful for residents. In this context, Tayfur and Arslan (2013) observed, for example, that the lack of supervisory support and high workload impacted not only emotional exhaustion, but also the perception of physician–patient reciprocity. In terms of application, the knowledge of these moderating factors, as well as the different processes linking burnout and empathy raised by the residents, will enable the pathogenic effects of burnout on the clinical practice of health providers to be anticipated. This will also help identify ways to develop the ‘practice of empathy’ and thus improve indirectly the quality of life at work for health providers. This type of research can show when (i.e. in which conditions) and how empathy is beneficial, and when it is pathogenic. Thus, considering the potential impact of burnout on empathy, we suggest that activities related to the regulation of emotion and the prevention of exhaustion are necessary. Considering the impact of empathy and compassion on burnout, we emphasize the necessity to support, during residency, the notions of ‘the right distance’ or ‘the right proximity’ between health providers and patients. Collective debriefing, narrative medicine and role-playing games are specific activities that may help to develop the right distance, by working on perspective-taking ability. Finally, considering the protective effect of empathy, these results confirm that one must develop an empathic attitude and humanism during residency. Cultivating empathy in clinical practice and medical studies will help physicians and residents to be satisfied, thus preventing them from being in burnout. For this purpose, support groups, in which residents share how their empathy was beneficial for patients and for themselves, may be relevant training activities. A primary interest of our research is the collection of qualitative data, which at least partially completes the quantitative research on the links between burnout, health practitioners’ well-being and empathy. Further quantitative studies are envisaged, in order to evaluate the proportions in which the opinions diverge between the residents, while measuring their degree of agreement with the moderating factors that were identified in our study. As clinical empathy has several aspects, either affective or cognitive, further studies will be necessary to determine whether the contradictory effects of empathy observed, favoring or protecting against burnout, are linked to the type of empathy used. Such studies will provide a better understanding of the process of clinical empathy and its consequences on the health of practitioners and students in order to raise their awareness and to improve the teaching related to empathy given to medical students in the faculties. Disclosure statement The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
References Brazeau, C. M., Schroeder, R., Rovi, S., & Boyd, L. (2010). Relationships between medical student burnout, empathy, and professionalism climate. Academic Medicine, 85(Suppl. 10), S33–S36. doi:10.1097/ACM.0b013e3181ed4c47 Halpern, J. (2012). Gathering the patient’s story and clinical empathy. The Permanente Journal, 16, 52–54. Heje, H. N., Vedsted, P., Sokolowski, I., & Olesen, F. (2008). Patient characteristics associated with differences in patients’ evaluation of their general practitioner. BMC Health Services Research, 8, 178. doi:10.1186/1472-6963-8-178
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Hojat, M., Gonnella, J. S., Nasca, T. J., Mangione, S., Vergare, M., & Magee, M. (2002). Physician empathy: Definition, components, measurement, and relationship to gender and specialty. American Journal of Psychiatry, 159, 1563–1569. Lamothe, M., Boujut, E., Zenasni, F., & Sultan, S. (2014). To be or not to be empathic? The combined role of empathic concern and perspective taking to understand burnout in general practice. BMC Family Practice, 15, 1–7. doi:10.1186/1471-2296-15-15 Larson, E. B., & Yao, X. (2005). Clinical empathy as emotional labor in the patient–physician relationship. JAMA, 293, 1100–1106. Mazurkiewicz, R., Korenstein, D., Fallar, R., & Ripp, J. (2012). The prevalence and correlations of medical student burnout in the pre-clinical years: A cross-sectional study. Psychology Health & Medicine, 17, 188–195. Neumann, M., Edelhäuser, F., Tauschel, D., Fischer, M. R., Wirtz, M., Woopen, C., … Scheffer, C. (2011). Empathy decline and its reasons: A systematic review of studies with medical students and residents. Academic Medicine, 86, 996–1009. doi:10.1097/ACM.0b013e318221e615 Nielsen, H. G., & Tulinius, C. (2009). Preventing burnout among general practitioners: Is there a possible route? Education for Primary Care, 20, 353–359. Tayfur, O., & Arslan, M. (2013). The role of lack of reciprocity, supervisory support, workload and work–family conflict on exhaustion: Evidence from physicians. Psychology, Health & Medicine, 18, 564–575. doi:10.1080/13548506.2012.756535 Thomas, M. R., Dyrbye, L. N., Huntington, J. L., Lawson, K. L., Novotny, P. J., Sloan, J. A., & Shanafelt, T. D. (2007). How do distress and well-being relate to medical student empathy? A multicenter study. Journal of General Internal Medicine, 22, 177–183. doi:10.1007/s11606006-0039-6 Truchot, D., Roncari, N., & Bantegnie, D. (2011). Burnout, patient compliance and psychological withdrawal among GPs: An exploratory study. Encephale, 37, 48–53. doi:10.1016/j.encep.2010.03.011 Verheul, W., Sanders, A., & Bensing, J. (2010). The effects of physicians’ affect-oriented communication style and raising expectations on analogue patients’ anxiety, affect and expectancies. Patient Education and Counselling, 80, 300–306. doi:10.1016/j.pec.2010.06.017 Zenasni, F., Boujut, E., Bluffel du Vaure, C., Catu-Pinault, A., Tavani, J. L., Rigal, L., … Sultan, S. (2012). Development of a French-language version of the Jefferson scale of physician empathy and association with practice characteristics and burnout in a sample of general practitioners. International Journal of Person-Centered Medicine, 2, 759–766. doi:10.5750/ijpcm.v2i4.295 Zenasni, F., Boujut, E., Woerner, A., & Sultan, S. (2012). Burnout and empathy in primary care: Three hypotheses. British Journal of General Practice, 62, 346–347. doi:10.3399/bjgp12X652193 Zwack, J., & Schweitzer, J. (2013). If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Academic Medicine, 88, 382–389. doi:10.1097/ACM.0b013e318281696b
Psychology, Health & Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/cphm20
Burnout, empathy and their relationships: a qualitative study with residents in General Medicine a
a
b
Jeanne Picard , Annie Catu-Pinault , Emilie Boujut , Marion c
a
Botella , Philippe Jaury & Franck Zenasni
c
a
General Medecine Department, Université Paris Descartes, Sorbonne Paris Cité, Paris, France b
Laboratoire Psychopathologie et Processus de Santé, Institut Universitaire de Psychologie de Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Boulogne-Billancourt, France
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c
Laboratoire Adaptation Travail Individu, Institut Universitaire de Psychologie de Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris cité-Sorbonne, 71 avenue Edouard Vaillant, 92100 Boulogne-Billancourt, France Published online: 15 Jun 2015.
To cite this article: Jeanne Picard, Annie Catu-Pinault, Emilie Boujut, Marion Botella, Philippe Jaury & Franck Zenasni (2015): Burnout, empathy and their relationships: a qualitative study with residents in General Medicine, Psychology, Health & Medicine, DOI: 10.1080/13548506.2015.1054407 To link to this article: http://dx.doi.org/10.1080/13548506.2015.1054407
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
Downloaded by [UNSW Library] at 08:23 14 August 2015
This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Psychology, Health & Medicine, 2015 http://dx.doi.org/10.1080/13548506.2015.1054407
Burnout, empathy and their relationships: a qualitative study with residents in General Medicine Jeanne Picarda, Annie Catu-Pinaulta, Emilie Boujutb, Marion Botellac, Philippe Jaurya and Franck Zenasnic* a
General Medecine Department, Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Laboratoire Psychopathologie et Processus de Santé, Institut Universitaire de Psychologie de Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Boulogne-Billancourt, France; c Laboratoire Adaptation Travail Individu, Institut Universitaire de Psychologie de Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris cité-Sorbonne, 71 avenue Edouard Vaillant, 92100 Boulogne-Billancourt, France
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b
(Received 15 January 2015; accepted 19 May 2015) Some studies have shown that burnout may have a negative impact on clinical empathy during internship. However, clinical empathy may also be a protective factor, preventing residents from experiencing burnout. Although several quantitative studies have been conducted to examine these relationships between burnout and empathy, no qualitative studies have been carried out. To examine how residents in general practice evaluate the link between burnout and empathy, 24 of them participated in a semistructured interview. A thematic analysis was carried out to examine residents’ discourses and answers to closed questions. The results indicated that residents thought that empathy and burnout were clearly related in different ways. They identified five types of relationship: regulation strategy, empathy as protection, psychological balance/imbalance, fatigue and moderating factors. Keywords: burnout; empathy; residents; compassion
Clinical empathy appears to be a non-technical core competence in primary care (Halpern, 2012; Hojat et al., 2002), and is a quality widely expected by patients. Studies have shown that it favors physician–patient relationships and significantly reduces medical errors (Heje, Vedsted, Sokolowski, & Olesen, 2008; Verheul, Sanders, & Bensing, 2010). Despite its importance, clinical empathy is rarely performed or developed. It could even decrease during medical school and residency (Neumann et al., 2011). Several factors may explain this dulling of empathic skills during internship, one of which is the well-being of residents, which is directly related to their empathic potential. Mazurkiewicz, Korenstein, Fallar, and Ripp (2012) explained that high levels of burnout may be observed during medical school and this has a significant impact on residents’ health and, potentially, on their non-technical skills. Several quantitative studies have tested the relationships between burnout and empathy, concluding that burnout hinders the expression of empathy. Thomas et al. (2007) observed that low well-being was related to lower medical student empathy. Brazeau, *Corresponding author. Email: [email protected] © 2015 Taylor & Francis
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Schroeder, Rovi, and Boyd (2010) reported that the higher the level of burnout, the lower the self-reported empathy of general physicians. Similarly, Zenasni, Boujut, Buffel du Vaure et al. (2012) observed that the higher the level of burnout of general practitioners, the lower their empathy. Although these studies have confirmed a significant relationship between burnout and empathy, they have not identified the factors and/or processes underlying these associations. Recent research has begun to address this issue. Lamothe, Boujut, Zenasni, and Sultan (2014) detailed the nature of these relationships by taking into account two distinct components of empathy: perspective concern and perspectivetaking. They showed that while low perspective-taking is a risk factor for burnout, high levels of perspective-taking and perspective concerns may prevent a physician from being in burnout. These results are in line with those of Zenasni, Boujut, Woerner, and Sultan (2012) who proposed that burnout and empathy might be interrelated in three different ways. First, burnout and empathy are related because the physician’s burnout impacts their empathic potential. From this perspective, burnout, induced by organizational or dispositional causes, will reduce empathy, at least in part, due to its depersonalization effect. Health providers in burnout will tend to prefer solutions of psychological withdrawal (Truchot, Roncari, & Bantegnie, 2011). Thus, exhausted physicians will be less able to put themselves in the patient’s shoes and to demonstrate empathic listening, and will prefer to protect themselves by keeping the patient at a distance and depersonalizing them. Second, empathy causes burnout due to a greater investment in the pain and emotions of others, leading to exhaustion. A high level of emotional concern may cause ‘compassion fatigue,’ which in turn induces exhaustion and burnout. For Nielsen and Tulinius (2009), compassion fatigue in general practice refers to ‘being exhausted emotionally’ due to frequent difficult patient encounters, associated with the need for high attention and empathic listening. However, this view involves a specific definition of empathy, focusing on affective aspects. One inappropriate consequence of affective empathy is that physicians may become too concerned with the feelings of the patient and thus offer improper compassionate care. Third, the empathic actions of health practitioners may prevent them from experiencing burnout. Halpern (2012) suggested that a well-proportioned empathy might enhance job satisfaction and thus reduce the risk of burnout: being empathic implies being aware of one’s own negative emotions, practicing self-reflection and accepting negative feedback, which are resources that can be used against stress and burnout. The results of Lamothe et al. (2014) confirmed this third perspective by showing that empathy is associated with less emotional distress. Based on the works of Zwack and Schweitzer (2013), they verified the idea that good interactions with patients will promote patient gratitude, which in turn is a source of strength and satisfaction for the physician. Although recent quantitative studies may help to infer and confirm, at least in part, these three types of relationship (Lamothe et al., 2014), qualitative studies are also helpful since they can show how burnout and empathy interact and give rise to these three potential effects. With this objective, the present research aims to explore the potential factors and processes underlying burnout–empathy relationships, by interviewing residents in general practice.
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Methods Participants Residents in general practice were recruited from Parisian universities. They were considered eligible if they were aged from 20 to 35 years, registered on a specialized degree course (general medicine) and fluent in spoken French. Twenty-four residents (12 men, 12 women) aged from 25 to 30 years (mean age = 27.3 years) were recruited. Two refused to participate without giving any specific reason. Eight were in their first year of residency, three in their second year, twelve in their third year and one in their fourth year.
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Material Based on a literature review and experience feedback from residents, we developed a semi-structured interview guide. In the first part of the interview, residents were asked to describe their current internship. Then, they answered open-ended questions concerning (1) the representations and definitions of empathy (‘What is empathy for you? In general? In your medical practice?’), (2) the importance and the impact of empathy for their medical practice, (3) the way empathy may improve the care of patients, (4) the impact of the use of empathy on their own health and (5) the potential relationships between empathy and burnout. The second part of the interview included three questions related to the three hypotheses linking empathy and burnout: ‘Do you agree that (1) burnout decreases empathy due to depersonalization?’ (2) empathy favors burnout because of compassion fatigue?’ and (3) empathy prevents one from being in burnout?’ For each hypothesis, residents were asked to develop their answers. Procedure Residents were contacted by mail or by phone during their internship. When they agreed to participate, they met the interviewer in a quiet room in a face-to-face position. The demographic data of the participants were collected before the start of the interview. All the interviews were recorded with the oral consent of the participants. Results Empathy and burnout: open interviews A thematic analysis was conducted to identify how residents related empathy to burnout. Five main topics were extracted: empathy as protection, regulation strategy, psychological balance, fatigue impact and moderating factors (Table 1). Regarding protective empathy (Theme 1), 10 residents considered empathy useful for the practice of medicine and necessary for their own satisfaction and achievement in their work: ‘It makes me feel good to have empathy for people, it’s never hurt me, I’ve always felt more satisfied when I’ve thought I’ve succeeded in understanding someone, in sharing their feelings a little bit.’ Although empathy was beneficial for care, most residents stated that its use/practice had a direct impact on their emotional states and might create fatigue (Theme 2), which affected their interactions: ‘There are some days when listening to patients is tiring and then we are no longer sensitive to their problems.’; ‘I think that an exhausted physician can’t think of others and take care of them.’ Thus, because empathy may have a damaging impact, some residents suggested that it
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Table 1.
Thematic matrix based on the resident interviews.
Topic
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Empathy is protective Workload affects empathy Regulation strategy Psychological balance/imbalance Moderating factors Identification with patients Knowledge/abilities relative to empathy Stress factors/organizational constraints/gratitude
Number of residents mentioning the topic (men/women) 10 (7/3) 5 (3/2) 12 (4/8) 9 (4/5) 14 (10/4) 5 (3/2) 4 (3/1) 5 (4/1)
must be carefully regulated in order to stay applicable and to avoid exhaustion or burnout (Theme 3): ‘You mustn’t get too deeply involved because that’s exhausting and afterwards, well what can I say, you have to stand back because it weighs you down.’; ‘You have to learn to control this empathy.’ Several residents pointed out the need to maintain a distance between themselves and their patient and to find a balanced attitude (Theme 4). Otherwise, empathy may create too much compassion, which in turn may create emotional difficulties: ‘And if there’s too much empathy, I know that that could overwhelm me.’; ‘In my opinion, too much empathy would not be beneficial, […] well, you have to find the right path between the two.’ This equilibrium, according to some residents, seems to depend on specific factors, which we call moderators (Theme 5) since they moderate the impact of empathy on burnout or the impact of burnout on empathy. Three kinds of moderator were mentioned by residents. They refer to (1) the identification with patients, (2) knowledge/abilities relative to empathy (3) and stress factors (see Table 1). The most frequent moderator is the ‘identification’ with a patient. Some residents suggested that empathy favored compassion then burnout when a patient reminded them of a specific important person (a parent, a friend, etc.) or even themselves: ‘There are illnesses which remind me of close friends or relatives, or make me think about myself, so that means I’ll be more empathic.’ Some moderators refer to the ‘savoir faire’ of residents in relation to empathy: knowledge, learning, abilities or experiences about empathy may prevent residents from becoming exhausted: ‘If you know how to manage a consultation, you waste less time, you don’t go back over other things, and you can be more empathic and have less burnout.’ Finally, the last kind of moderator refers to the organizational or contextual situation, which may favor stress and then condition the change of empathy into burnout. These moderators refer to workload, stress factors or lack of gratitude from the patient: ‘Maybe some people are too empathic, but if their workload was adapted, […] they wouldn’t be depressed or have burnout and so on. […] Maybe someone is very empathic and has a huge workload, and that’s it!’ Opinions about the three proposals We observed (see Table 2) that a large majority of the interviewed residents (87.5%) agreed with the first proposal indicating that burnout has an impact on empathy.
Psychology, Health & Medicine Table 2.
Resident answers to the three propositions.
Propositions Proposition 1: Burnout impacts empathy due to a depersonalization effect
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Residents agreed (men/women) 21 (12/9)
Explanations • •
•
General loss of interest (n = 3) Loss of interest in patients (n = 13) ○ No interest in patients (n = 7) ○ Being selfcentered (n = 2) ○ Self-protection (n = 2) ○ Objectification of patients (n = 2) Fatigue (n = 2)
Proposition 2: Empathy favors burnout because of compassion fatigue
12 (3/9)
• •
Overload (n = 8) Lack of coping strategy (n = 2)
Proposition 3: Empathy prevents burnout because of satisfaction at work
16 (8/8)
•
Feeling of helping (n = 5) Gratitude/feedback from patients (n = 3) Satisfaction with the work done (n = 2) Relational interest of the job (n = 2)
• • •
Three of them suggested that this loss of interest was general: ‘When you are in that phase, you’re no longer open to anything.’ Thirteen specified that this loss of interest was specific to relationships with patients. Thus, seven residents stated a loss of interest in patients: ‘I only wanted to do the technical aspect and I didn’t feel like talking to people.’ Two residents put forward the idea that stepping back was a kind of self-protection: ‘If you are in burnout you are already weighed down by what’s happening to you and you need to protect yourself, you can’t feel other people’s pain as well.’ Two residents indicated that this withdrawal was associated with an objectification of patients: ‘I think it’s true because you don’t have too much empathy any more when you’re in burnout, you see the patients more as a number and you try to treat them.’ Finally, supporting the first proposal, two residents suggested that burnout affected empathy due to fatigue: ‘I’m sure that when you’re exhausted, when you’re fed up, when you’re overwhelmed by tiredness and your feelings, it’s hard to have empathy.’ Concerning the second proposal, 50% of the residents thought that empathy favored burnout due to compassion fatigue. Eight of them said that empathy generated burnout by creating an emotional labor and workload: ‘I think that the resident is so filled with emotion that, at some point, it’s only natural that it causes compassion fatigue.’ Two residents suggested that compassion might be due to a lack of coping with the situation:
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If you go further than empathy and it’s no longer just empathy, then there’s a risk of burnout because you’re going to find yourself in situations that you can’t manage, you can’t control your feelings and then you’re at risk of burnout.
Concerning the third proposal, 66.6% of the residents thought that empathy might prevent burnout. They considered empathy an important component of job satisfaction. Thus, five residents indicated that feeling that they were helping people increased their satisfaction and even enriched them: ‘Because when you feel that you’ve helped the patient, somehow you’re happy. It’s through empathy and through those you can help that you can fix things a bit.’ This sense of helping was also mentioned by three residents in terms of patient gratitude: ‘They’re people who really like to be thanked and who like to be recognized for the work they do.’ Two residents talked in terms of job satisfaction: ‘I think that empathy can reduce burnout, in fact, because you’re happier with the work that you do.’ Two other residents emphasized the relational interest of their job: ‘I didn’t choose this profession for the technical aspect, it’s really for the contact with people, and so if I’m deprived of that, […], I would be worse off.’ Discussion The aim of the present study was to examine how residents in general practice related empathy and burnout. For this purpose, qualitative research was carried out by conducting semi-structured interviews. The results indicated that residents thought that empathy and burnout were clearly related in different ways. Most residents agreed that burnout impacted empathy due to a depersonalization effect. They frequently described these effects of burnout as the development of a loss of interest, which might be general or specific to resident–patient relationships. Burnout favored a kind of detachment from the context or from other people. Detachment was expressed in terms of ‘self-centeredness’ or voluntary withdrawal in order to protect themselves. We also observed that empathy might appear as protective or safeguarding for residents. In fact, as suggested by Lamothe et al. (2014), it provided satisfaction at work, particularly when there were feelings of a job well done, of social relationships with patients and of helping, especially when patients expressed some gratitude or gave feedback to residents. In this perspective, empathy appeared mostly as a personal accomplishment at work rather than an emotional labor. However, to a lesser extent and in line with previous theories (Larson & Yao, 2005; Neumann et al., 2011), the practice of empathy may also be considered emotional labor. Half of the interviewed residents agreed with the idea that empathy favored burnout because of compassion fatigue, or even general fatigue. Being empathic or too empathic might provoke overload at work, particularly when residents could not cope with situations, and put limitations on their interactions. This is why some residents mentioned the need for a regulated coping strategy in order to not go too far and lose psychological and relational balance. A last important point observed in the residents’ discourses is that the links between burnout and empathy might depend on specific conditions and/or factors. These moderating factors might be considered triggering variables, which might favor the path from empathy to the presence or absence of burnout or the path from burnout to a lack of empathy. Thus, we observed that identification with patients might be crucial to explain why some residents felt compassion and then risked burnout. Similarly, empathy might become dangerous if it interacted with organizational constraints or other stress factors. On the other hand, acknowledgment by patients, and knowledge and skills in
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clinical empathy seemed to be factors considered helpful for residents. In this context, Tayfur and Arslan (2013) observed, for example, that the lack of supervisory support and high workload impacted not only emotional exhaustion, but also the perception of physician–patient reciprocity. In terms of application, the knowledge of these moderating factors, as well as the different processes linking burnout and empathy raised by the residents, will enable the pathogenic effects of burnout on the clinical practice of health providers to be anticipated. This will also help identify ways to develop the ‘practice of empathy’ and thus improve indirectly the quality of life at work for health providers. This type of research can show when (i.e. in which conditions) and how empathy is beneficial, and when it is pathogenic. Thus, considering the potential impact of burnout on empathy, we suggest that activities related to the regulation of emotion and the prevention of exhaustion are necessary. Considering the impact of empathy and compassion on burnout, we emphasize the necessity to support, during residency, the notions of ‘the right distance’ or ‘the right proximity’ between health providers and patients. Collective debriefing, narrative medicine and role-playing games are specific activities that may help to develop the right distance, by working on perspective-taking ability. Finally, considering the protective effect of empathy, these results confirm that one must develop an empathic attitude and humanism during residency. Cultivating empathy in clinical practice and medical studies will help physicians and residents to be satisfied, thus preventing them from being in burnout. For this purpose, support groups, in which residents share how their empathy was beneficial for patients and for themselves, may be relevant training activities. A primary interest of our research is the collection of qualitative data, which at least partially completes the quantitative research on the links between burnout, health practitioners’ well-being and empathy. Further quantitative studies are envisaged, in order to evaluate the proportions in which the opinions diverge between the residents, while measuring their degree of agreement with the moderating factors that were identified in our study. As clinical empathy has several aspects, either affective or cognitive, further studies will be necessary to determine whether the contradictory effects of empathy observed, favoring or protecting against burnout, are linked to the type of empathy used. Such studies will provide a better understanding of the process of clinical empathy and its consequences on the health of practitioners and students in order to raise their awareness and to improve the teaching related to empathy given to medical students in the faculties. Disclosure statement The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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