Kindness Begins with Yourself: Strategies to Engage Medical Trainees in Self-Compassion

Abstract

This chapter aims to expand upon the foundation of knowledge around self-compassion gained from Chap. 2, by helping the resident physician assess and reflect upon how they may offer kindness to themselves, and guide them in building upon this integral value. Practices that promote and foster self-compassion, kindness, and acceptance are reviewed. The reader is encouraged to explore these, discovering how this may help in coping with the stressors inherent to medicine and learning how such tools can be integrated into their lives and busy schedules. With ongoing practice and by adapting the tools to suit their own needs and preferences, residents may gradually feel more comfortable in becoming their own compassion leader.

Healing the Healer: How Self-Compassion Plays a Role

When asked what the most important component in their interactions with their physicians is, patients tend to highlight the concept of “humaneness,” even over competence [1]. The idea of humanity in medicine emphasizes certain traits of the provider, specifically placing high value on empathy, kindness, humility, honesty, and openness [2, 3]. This may come as no surprise, as physicians are often viewed by society as altruistic and trusted individuals, who have devoted their lives to serving their communities and whose intrinsic values revolve around connecting with, caring for, and supporting others. Yet, though these traits are often central to physician identity and personality, many physicians struggle to provide the same care, kindness, and concern for themselves and their own well-being.

Enter self-compassion! As taught in Chap. 2, this is a practice that is particularly useful as it combats both the individual and systemic factors that can place physicians at risk for burnout. By encouraging one to prioritize their own needs and adopt a gentler approach to themselves and their way of thinking, it can help those in medicine who persistently place high expectations on themselves, who struggle with chronic self-doubt or self-deprecation, or who have a particularly loud or harsh internal critic. As shown in Table 15.1, the core elements of self-compassion also help the provider develop approaches to minimize and counteract harmful negative or self-critical elements, which can be promoted or reinforced by the culture of medicine and hidden curriculum, and ultimately drive burnout [4]. As such, self-compassion for the physician can work to reduce or prevent burnout, stress, anxiety, perfectionism, compassion fatigue and depression, as well as improve empathy, relationships with others, and promote overall happiness and motivation [5, 6].

Table 15.1 Self-compassion vs. self-criticism in medicine

Though it may be widely believed that compassion is an innate trait and that one is either compassionate or not, the good news is that self-compassion is a skill that can be learned, although it takes time and practice. While reading through this chapter and engaging in these practices, it can be helpful to consider self-compassion like a muscle, which needs to be regularly exercised and engaged, in order to build strength and endurance so that physicians and physician trainees can not only survive but also thrive in the marathon of life.

Of note, many of the ideas contained within this chapter are those of the authors themselves, who include a resident physician and an early-career practicing physician. By sharing ideas based on their own personal training and life experiences, it is their hope that other medical trainees and healthcare providers may be able to relate to such thoughts and examples.

This chapter contains several exercises intended as a general introduction to self-compassion practices. Some of these exercises have been adapted for the healthcare provider based on “The Mindful Self-Compassion Workbook” and “The Mindful Self-Compassion Course,” both by Kristin Neff and Christopher Germer, the co-developers of mindful self-compassion [ 7 , 8 ] . For a more comprehensive understanding of self-compassion, guidance into the practice, and a list of exercises and meditations, please utilize the resources listed at the end of the chapter (See section “Additional Resources”, Table 15.2 ).

Table 15.2 Selected resources about the practice of self-compassion

Skill-Building Exercise: How Self-Compassionate Are You?

Before beginning to explore self-compassion practices and interventions, it is important to check in and build self-awareness. Consider reflecting on the following questions:

• Am I a kind and compassionate person?

• How do I display kindness and compassion in my role as a physician?

• Am I kind and compassionate with myself?

• Do I treat myself differently than I might a loved one, a close friend, or a patient?

• What might be getting in the way of being kind and compassionate toward myself?

If you are having any difficulty answering these questions or wish to have a more concrete baseline measure of your self-compassion, consider completing a free validated self-compassion questionnaire available online (See section “Additional Resources” Table 15.2) [9]. This will help to further develop your understanding of how you are doing with regards to expressing self-compassion and identify challenges or internal barriers that may be perpetuating self-criticism. This questionnaire can also help you gauge your progress down the road after some time has been spent building on this skill.

Keeping It Simple: Finding Small Ways to Give a Little Love to Oneself

Initially, the task of adopting a more self-compassionate mindset may seem daunting and effortful; however, it is important to remember that kindness and humanism are qualities innate to every human being. Physicians are well versed in caring for others, but occasionally may require reminders to turn the spotlight internally and become more attuned to this need for caring within themselves.

Self-compassion can be integrated into one’s life in various small, yet meaningful, ways. This section introduces the approach of informal self-compassion, which can be used during a moment at home, in the hospital/clinic, or in daily encounters with patients or colleagues. This is a good starting point for beginners, skeptics, and those who may find it difficult to engage in deeper and longer formal meditations. More intensive self-compassion practices and meditations will be explored in the sections that follow.

Attuning to One’s Own Needs: Self-Compassion in Daily Life

Self-compassion involves, in part, a cognitive element. It is a practice that may shift or alter one’s thinking patterns and the way in which one perceives and treats themself. However, the scope of self-compassion goes beyond this. The practice of self-compassion can also help promote behaviors and actions that foster self-care, help one live in line with one’s values, and serve as a reminder of one’s own needs.

Physicians and healthcare providers may find it particularly challenging to adopt behaviors that promote their own self-care. It is common to prioritize patients’ needs and health over their own, and much of their time is devoted to patient care and continuing educational enhancement such that there is barely time to fulfill basic physiologic and psychological needs. When training responsibilities and clinical duties mount, self-care practices, coping skills, and even basic physiological needs are often first to be sacrificed and risk being pushed to the backburner. They tend to be used infrequently, and often only when reaching the point of exhaustion, a time when they no longer hold the same effect. This is where behavioral self-compassion can be helpful, as it provides permission and space for the provider to prioritize taking care of themselves and try to regain the balance between their own needs and those of their patients and workplace. To practice this self-compassion in daily life, consider utilizing the steps outlined in Fig. 15.1.

Fig. 15.1

The 3 R’s of daily self-compassion. (Adapted form [7])

It is not uncommon for individuals to become stuck when trying to work out how best to respond to their own needs. Over the course of training, many physicians may have become distant from the people, places, activities, and things that provide joy and comfort, and reduce tension and stress. For those who encounter this roadblock, it can be helpful to reflect on how one has managed or coped with stress in the past and found respite and relaxation. Figure 15.2 offers guidance to help remind healthcare providers of the tips and tricks they have used in the past to maintain their wellness.

Fig. 15.2

The 3 R’s of troubleshooting daily self-compassion

Grounding Oneself: Soles of the Feet

Consider a time recently when there was overwhelming emotion, hurt, or frustration. Perhaps this was related to a challenging medical code, an upsetting interaction with a supervisor who was critical of the way a case was managed, or related to an argument with a partner after coming home late from clinic. Whatever the case may be, these experiences can be wrought with emotion and can negatively impact the rest of one’s day if there is not an opportunity, even so briefly, to take a bit of a breather and to process the difficult emotion.

The problem for practicing physicians and resident physicians, however, is that due to busy schedules and clinical responsibilities, finding the space and time to take a break, acknowledge emotions, and settle oneself can feel seemingly impossible. In many cases, the provider is forced to swallow and suppress these strong emotions, which continue to take a toll and erode their sense of well-being. This can later manifest as diminished presence and attentiveness in subsequent encounters, and being quicker to react or lose patience or one’s temper, which only pours further fuel on the fire. So how can this harmful cycle be broken?

One option is to engage in grounding. The practice of utilizing and focusing on one’s feet is an established practice in mindful self-compassion. While seemingly simple, this practice has been shown to help regulate emotions [10]. By connecting with the feet, even for just a few moments, attention is directed to the point furthest away from the busy mind and negative thoughts, allowing some needed space to settle and calm [7]. It is also an exercise that fosters mindfulness, allowing one to let go of the past, even briefly, such that one can better attune to the present moment and refocus their efforts and energy more productively. As illustrated in Fig. 15.3, this practice is not onerous and can be practiced any time, including while sitting with a patient, during team rounds, or when walking to and from exam rooms, making it ideal for the healthcare provider who is constantly on the go.

Fig. 15.3

How to: Connecting with the soles of your feet. (Adapted from [7])

Comforting Oneself: Soothing Touch

Medicine can be a challenging profession. Healthcare providers devote their lives to caring for their communities and promoting others’ health and well-being, which can be incredibly meaningful. However, they are also frequently exposed to trauma and tragedy, pain and suffering, and death and dying, which can take an emotional toll. On some level, providers may recognize that as humans, no one is perfect. Medical mistakes can and do happen, and despite the best efforts and the newest treatments, no one is 100% successful when it comes to saving or curing patients. Though suffering, death, and loss are universal to the human experience, perfection and high success rates can at times appear to be the expected outcome for the physician. They are immersed within a medical culture that can reinforce internal and external demands to be “superhuman.” Physicians are often expected to avert failure, and also experience pressure to mask vulnerability and maintain composure during the darkest and most difficult times. This is a “considerable task. Yet the classic mantra says it best, everyone “keeps calm and carries on.” They continue to carry this burden, these distressing experiences, and these troubling fears and worries, all alone. So how can one cope with this? While debriefing and peer support are important in such cases, providing self-comfort can also be effective and can be as simple as utilizing physical touch.

“Soothing touch” is a core component of many self-compassion practices [7, 8]. For some, it may seem a little silly to provide physical touch to themselves; however, most would likely agree that a hug from a loved one, a hand from a concerned friend, or being offered a shoulder to cry on by a trusted individual can be incredibly powerful. This expression of love and compassion thwarts the fight-or-flight stress response and fosters a sense of safety [11], which together work to facilitate the expression and release of difficult emotions or experiences, mitigate self-criticism, and help to calm and soothe. Soothing self-touch, as outlined in Fig. 15.4, works in a similar fashion, by utilizing a combination of mindfulness and self-kindness.

Fig. 15.4

How to self-soothing with physical touch. (Adapted from [7])

While traditional soothing touch practices most commonly utilize the placement of the hand on the heart (as demonstrated in Fig. 15.4), this may not be the most comfortable position for everyone and may not always be the most discrete for those who wish to do the exercise in public. As such, with this practice it can be helpful to spend time experimenting with other ways to engage in self-touch, to see what feels best. Examples of alternative gentle touch positions are listed in Fig. 15.5.

Fig. 15.5

Alternative soothing self-touch positions. (Adapted from [7])

Did You Know?

Similar to the effects of soothing touch from others, engaging in self affectionate touch can trigger release of oxytocin, promoting positive emotions and well-being, and reduces the release of cortisol (the stress hormone) [7, 12].

Offering Kindness to Ourselves: Loving Kindness Moments

As shown in Chap. 2, the principles of self-compassion include a triad of mindfulness, embracing common humanity, and self-compassion [13]. While the above exercises utilize one or two of these dimensions, loving kindness moments (also known as the “self-compassion break” [7]) is a practice that encompasses all three principles.

Mindfulness here permits the recognition and validation of the hurt and distress that is being experienced, which works to limit judgment and prevent the cycle of rumination. Next, individuals normalize their experiences and emotions, remembering that these can be common experiences that are shared with others, including our colleagues in medicine who similarly experience and understand our stress and struggles. This helps to mitigate the sense of isolation and loneliness that physicians and trainees may experience. Lastly, to foster self-kindness, individuals can offer caring or warm words to themselves, which work to provide comfort and compassion and increase motivation to take positive action. Figure 15.6 provides specific steps on how to carry this out.

Fig. 15.6

The 5 N’s of daily loving kindness. (Adapted from [7])

Loving kindness moments can be utilized in our daily life whenever difficult or stressful moments arise, which requires no more than 5 minutes of time, making it amenable for those whose time is scarce. This can also be a helpful exercise to practice and feel comfortable with before moving on to some of the more intensive exercises, which will expand on these principles.

Skill-Building Exercise: Loving Kindness Moments in Action

Case Scenario

Julie is an emergency medicine resident working a shift at one of her city’s trauma centers. She is assigned to a patient who presents acutely agitated with an unknown toxidrome that has necessitated physical restraints in order to obtain necessary vitals and investigations and to maintain safety for both the patient and staff. Despite the use of a low-stimulation environment and Pinel restraints, the patient remains highly agitated. They scream, swear, and thrash about so violently that staff are concerned that the patient may cause injury to themselves or overturn the stretcher. Julie decides that chemical restraint is needed and orders IM lorazepam. While inputting the order into the EMR, she is called to assist with another patient who is crashing, and so hastily finishes the order, during which time she accidentally authorizes double the dose she had been intending. When Julie returns some time later, she finds the patient somnolent and difficult to rouse. She reviews the chart and identifies her error. Julie feels terribly about this. She reports the incident to her staff, files a medical error report, and requests close clinical monitoring for the patient, but remains highly anxious and unable to focus.

If Julie were to practice a moment of loving kindness in this situation, it may look something like this:

• 1. Take Note: Julie identifies that the encounter with this agitated patient in which she made a medical error is what is contributing to her current anxiety and stress.

• 2. Notice: She takes a few seconds to check in with her body. She notices discomfort in the form of tension in her neck and shoulders, as well as in her chest. While at the charting station alone, she places her hand over her heart as a way to ground and soothe herself.

• 3. Naming: Julie recognizes that her reaction to this situation is fueled by feelings of guilt, shame, and anger with herself. Immediately she begins to chastise herself, and all of her shortcomings as a resident flood her mind, which is hard to ignore. She tries to let go of these judgments by visualizing these thoughts being placed on a leaf which floats down a stream and simply reminds herself that it is ok that she is feeling this way, as this is certainly a stressful situation.

• 4. Normalizing: Julie considers other residents she knows and reminds herself that her anxiety and guilt are understandable, as if others were in her shoes, they would likely feel the same. In fact, she recalls that several of her co-residents and preceptors have shared with her stories of medical errors that have been made over the years. This helps her feel less alone and serves as a reminder that she is only human and can learn from this situation to improve patient safety.

• 5. Neutralizing: Julie reminds herself that the error was not intentional and that mistakes can and do happen, despite the best efforts and precautions. She recalls that she is still training, but can use this as a learning point going forward when involved in more high-stress and high-acuity situations requiring her to multitask. She then offers herself a needed wish, repeating to herself, “for this moment, may I have the courage to carry on,” which allows her anxiety to quell enough that she is able to refocus on her patients and the tasks ahead.

Putting It into Practice

Julie’s case is one specific example of how loving kindness moments can be integrated into practice. There are a variety of situations, however, that providers face every day where this practice can be utilized.

Consider now for a moment if there is a situation that you have been sitting with or that has been weighing on you lately. Perhaps this was an event that was stressful, anxiety-provoking, or perplexing. Perhaps this is related to an error or near miss like Julie experienced, uncertainty in a clinical situation, an adverse patient outcome, or feeling unequipped or lacking time to manage all of the tasks and responsibilities on your plate.

Now that you have the situation in mind, utilize the 5 N’s as outlined in Fig. 15.6 to practice using loving kindness here. Afterward, reflect on what this was like for you. Consider whether this helped you to process the emotions that you were experiencing, and if utilizing compassion, rather than criticism, worked to motivate you to continue facing this difficult situation or helped in getting ‘unstuck’ from it in your mind.

Consider utilizing this practice with ongoing difficult encounters or stressful situations either in the moment if you have time or after when you recognize it is still lingering with you.

For additional resources and guided meditations, the reader is directed to section “Additional Resources”, Table 15.2.

Did You Know?

Many find the self-kindness component of this practice to be the most difficult, as they ponder and ruminate about the right language or wording of their phrases and wishes for themselves. It is important to remember that the goal of fostering self-kindness is to lessen the harshness and intensity of the thoughts and emotions that have arisen and to provide a needed reminder of what it is that we need at that moment to move forward without getting stuck. What feels right and appropriate will be unique to each person and can change over time based on what it is they need to hear during these moments.

Some tips for finding what works include the following:

• Using common stems to get started such as “May I …” or “For this moment …”

• Consider what you might say to a friend or patient if they were facing the same challenge or experience

Reflecting Compassionately on Our Work: CARE Model

Physicians throughout their careers face frequent feedback and evaluation by their supervisors in medical training, colleagues, licensing bodies and regulatory colleges, and patients and their families; however, among all of this input, physicians still tend to be their own harshest critic. Whether by the nature of the culture in which they are enmeshed, or related to certain personality traits such as perfectionism and “obsessionality,” physicians are known to be strongly committed to their work, highly conscientious, and set very high standards for themselves when it comes to the care they provide [14]. The problem, however, is that this can lead physicians to begin viewing their work through a narrow and negative lens, through which self-doubt, self-blame, and rumination creep in, making it difficult to let go of work and setting the stage for burnout.

To help combat this cycle, physicians and medical trainees need time and space to reflect on and process their clinical encounters and training experiences, but importantly from a compassionate and growth-oriented perspective. While there is educational value in reflecting on a case to determine how one can improve, taking a balanced approach in which one is gentler with themselves can help reframe one’s thoughts in a way that promotes gratitude, relaxation, and the ability to disconnect from work, and boosts mood and self-esteem [15, 16].

While it may seem daunting to consciously monitor for self-criticism and negative cycles of thinking, and to know when to actively intercede, there are a number of simple methods to foster a more compassionate mindset in just a few minutes. One way is through the CARE model, developed by Drs. Tara Riddell and Ana Hategan. This is a four-step checklist, based on the positive psychology literature, which suggests that adopting a 1:3 negative to positive emotion ratio is most ideal for promoting wellness [15]. As outlined in Fig. 15.7, these four quick steps can be done in just 1–2 minutes. Together, they offer (1) a moment of grounding; followed by (2) acceptance of what was difficult, and acknowledgement of what went well or for which one is grateful; (3) enacting compassion and care for both the provider and involved colleagues; and lastly (4) planning for self-care after one’s shift or day.

Fig. 15.7

CARE  – Compassionate acceptance and reflection of our efforts

Skill-Building Exercise: CARE

Case Scenario

Megan is a surgery resident who just finished what felt like an incredibly long day. She feels exhausted and disheartened by the day’s events, which involved a few adverse outcomes including a patient who died from a postoperative complication and another patient who was badly injured in a car accident, whom her team had tried to save during a trauma surgery, without success. All day Megan has been replaying the surgeries and her encounters with these patients, wondering over and over again whether she could have done something differently to result in a better outcome. Usually, after leaving work Megan would head home, her mind still on work and questioning her decisions and skills. Today however, just before she leaves the learner lounge, she notices the CARE checklist, which is hanging on the back of the door.

Intrigued, Megan decides to give this a try. She takes a few deep breaths in and out, notices her feet firmly in contact with the ground, and then reflects back on the day acknowledging that this was a hard day for everyone involved, including herself, her patients and their families, and others on the team.

Using the 1:3 rule, Megan next considers the most challenging part of her day, which was informing a patient’s family that their loved one had passed away due to a complication from a surgery they had thought would permit them to live an otherwise long and healthier life. While Megan has been stewing in self-blame all day about this, she tries to reflect on this compassionately by reminding herself that despite the team’s best efforts, such complications and adverse outcomes can happen and that they did their best in caring for this patient. Megan acknowledges how difficult it was to provide bad news to the family and considers that next time she may take a few minutes to settle and soothe herself first so that she can be strong and present for the family. Though it is challenging to do so, Megan then lets these ruminating thoughts go, and moves on to focus on some of the positives of the day, which she finds more difficult than she initially expected. With some time, however, she is able to identify that she was pleased with her performance in a surgery today, acknowledging that her hours of studying had paid off as she was calm and focused, and received positive feedback from her supervisor. She also feels gratitude for the nurses, who provided close patient care and informed her as soon as they noted that one of her patients was declining, as well as her supervisor who noticed how upset she was after they provided bad news to the family today and offered to debrief with her. It was such physicians that inspired Megan to study medicine, and whom she strives to emulate when she becomes staff in a few short years.

In considering her colleagues, Megan thinks about one of the medical students who seemed quiet and withdrawn at the end of the day. Megan finds them before she heads home and checks in with how they are doing. The medical student discloses that this was the first time they encountered a patient death, which is weighing quite heavily on them. Megan spends a few minutes debriefing with the medical student and offering support, which is well received. They are able to share in this human experience together and both feel a little lighter as they leave the hospital. Megan considers what it is that she needs when she gets home to recuperate from the day and agrees to set some time aside for a hot bath and quality time with her partner before returning back to the books.

Putting It into Practice

This is one example of how the CARE model can be integrated into a physician’s busy day. Whether during lunch, between cases, or at the end of a call shift or day’s work, these four steps require only a few minutes to offer some valuable compassion to ourselves and those around us, yet can have a lasting effect.

Give this a try on your next shift, or even now if the day’s events are still weighing on you.

Kicking It Up a Notch: Intensive Self-Compassion Interventions

For those who remain interested in self-compassion, or wish to deepen their practice moving beyond informal interventions that can be done on the fly, there are several comprehensive practices that can be useful in this regard. These practices offer more advanced techniques, building on the informal exercises and meditations learned in the previous section. The formal practices address painful emotions such as anger or shame. They provide support in managing the most seemingly difficult or insurmountable experiences, such as those common to the healthcare provider who is searching for that tenuous balance between their own needs and those of others.

While there are many formal practices and guided meditations available, this section will provide exercises and practices that may be particularly useful to the perfectionistic and altruistic physician. We recommend reviewing the recommended resources listed at the end of the chapter for those who remain curious and interested in further building their toolbox of self-compassion practices (See section “Additional Resources”, Table 15.2).

Fostering Deeper Love for Ourselves: Written Compassionate Expression

Many individuals have kept a journal at some point in their lifetime, in which they chronicled the days’ events or shared their innermost feelings and secrets. Though years later some may laugh or roll their eyes at the content of their entries, in the moment many would likely attest that there is something enjoyable and beneficial in this form of self-expression. Perhaps this may be having a release for difficult emotions, such as anger, or feeling less alone and less burdened by what is troubling them. While the utility of journaling may not have been well understood in the past, there is now ample evidence to support the therapeutic nature of this form of written and emotional expression. Specifically, with regards to wellness, writing for personal benefit can help an individual become “unstuck” through processing challenging or distressing situations, offer validation and acknowledgment of an individual’s deeper feelings, and help them to construct a meaningful narrative of these events [17].

These benefits of written expression can be further amplified by integrating self-compassion. While this can be specifically achieved through various exercises, as will be explored below, utilizing the three principles of self-compassion in the form of writing can soften the intensity of the self-critical voice, in addition to offering some much needed and often-forgotten soothing and validation. Self-compassion through the use of common humanity also furthers a sense of community and provides comforting reassurance that no one is alone in these experiences, helping to mitigate the imposter syndrome.

The first method of written compassionate expression is in the form of compassionate journaling. This entails writing a narrative about a difficult or challenging experience. Examples may include the death of a patient, becoming frustrated and terse with a colleague when running a difficult code or managing a critical care situation, or feeling angry or upset when a patient became hostile and aggressive. Typical journaling often consists of documentation of the details of the situation and documentation of the emotions that arose in the context of this event. (See Chap. 14, Healthy Habits: Positive Psychology, Journaling, Meditation and Nature Therapy, for further details on journaling.) The application of self-compassion involves additional steps, as outlined in Fig. 15.8, to lessen the voice of the self-critic, to normalize and validate the experience and resultant reaction, and to help one effectively process and move forward by considering what is needed in order to do so. (See Chap. 14, for further details on journaling.)

Fig. 15.8

Four steps to compassionate journaling. (Adapted from [7])

Skill-Building Exercise: Compassionate Journaling

Give compassionate journaling a try! Obtain a notebook and try, even for just 1 week, keeping a self-compassion journal. Spend a few minutes prior to going to sleep, reflecting on the day’s events. Consider stressors arising from the rigorous training and responsibilities on your plate, or challenges that arose clinically with the patients you are caring for or during the course of your training. Use the steps from Fig. 15.8 to process this event or situation that continues to sit with you or is causing some degree of distress or discomfort.

After completion of your journal entry or upon reviewing it a few days later, reflect on the following questions:

• What was this experience like for you?

• How often did you notice your self-critic arising? How difficult was it to refrain from feeding this criticism?

• What did you notice when journaling or when re-reading your entries?

• How did this affect your emotions or the way in which you managed these difficult situations?

• After journaling on a few occasions, do you notice your critical voice lessening?

Another way of engaging in compassionate written expression is through the form of writing a compassionate letter to oneself. In this case, there is no necessity to focus on a troubling situation, but rather more broadly on one’s own perceived insecurities and inadequacies. For resident physicians, it is not uncommon to become highly focused and ruminative on one’s perceived weaknesses or failures, leading to perceive the self as not good enough, classic of the Imposter Syndrome [18]. Often this then evolves to feeling alone in one’s struggles and becoming disheartened and disempowered in one’s work, which can drive avoidance, cynicism, and ultimately burnout [18].

As such, compassionate letter writing can offer a provider the opportunity to view themselves – both strengths and weaknesses – from a warm and loving perspective offering both forgiveness and acceptance. This is important to ongoing work in healthcare and effective overall functioning in life, as it helps to instill motivation and encouragement in moving forward and to bettering oneself. While the ultimate goal in fostering self-compassion is to be able to write such a letter using one’s own compassionate voice, early in the practice this can be challenging. As such, for beginners, it can often be helpful to write a letter to oneself from the perspective of a close friend or trusted loved one. Figure 15.9 outlines the steps on how to craft a compassionate letter.

Fig. 15.9

Steps to writing a compassionate letter to oneself. (Adapted from [7])

Skill-Building Exercise: Compassionate Letters

Give compassionate letter writing a try! Whether on paper or using your computer, when you notice that you are feeling particularly poorly about yourself, are being overly critical, or fixating on a perceived negative aspect of yourself, try writing a letter using a compassionate voice (whether your own or that of a supportive friend, colleague, or loved one) using the instructions from Fig. 15.9.

After completion of your letter, read and reflect upon it. Make sure to hold on to this letter, as when other difficult times arise or when you again notice that critical voice rearing its head, it can provide you an opportunity to receive some needed compassion and remind you that you are cared for, valued, and that there will always be ongoing opportunity for personal growth.

Consider also reflecting on these questions:

• 1. What was this experience like for you?

• 2. What did you notice when writing your letter and when re-reading it afterward?

• 3. How did this affect your emotions and the way in which you understand and value yourself?

• 4. Did you notice over time that you were more easily able to accept and receive this compassion?

Balancing Kindness for Ourselves and Others as a Healthcare Provider: Giving and Receiving Compassion, and Compassion with Equanimity

Physicians devote their lives to caring for patients at some of their most vulnerable times. This requires various skills and knowledge, along with empathy as one of the most important and valuable physician characteristics. Empathy enables physicians to establish vital connections with their patients. This allows a physician to develop an understanding both of patient experience, which often involve pain and suffering, and of the meaning that this pain and suffering holds for them. A physician works to understand a patient’s pain by putting their own feet into the patient’s shoes. This is also known as emotional resonance, a process which not only leads to an affective response but also promotes hardwiring changes within one’s own neural networks [19]. For instance, studies have now uncovered that when one learns of another’s pain, this stimulates the same brain circuits and regions as if they were the one directly experiencing the pain themselves [20].

As a result of this, physicians can take on much of the pain and distress that they are witness to, which can lead to empathic distress or empathic fatigue. With empathic distress , providing or experiencing empathy for another can trigger discomfort or stir up one’s own distress related to previous memories, fears, or uncomfortable experiences [21]. Empathic fatigue , on the other hand, describes when providers feel drained and exhausted as they have continually and repeatedly experienced others’ suffering, which can become overwhelming and challenging to bear [21]. In either case, over time, providers may turn away from the discomfort as a way to cope and in an effort to reduce their own suffering. This can take various forms. One way physicians do this is by focusing predominantly on fixing the patient’s problem, rather than understanding the patient’s experience and attuning to their needs [7]. Another way is by creating boundaries with patients, which interferes with the physician’s ability to attentively listen and provide effective care [7]. This problem is often further compounded by the culture of medicine and healthcare systems which fail to provide essential time and space for providers to process and debrief traumatic or difficult encounters and to engage in self-care, which is one of the modalities to refuel and recharge.

So how then does one address empathic pain and suffering when it arises for the benefit of both the physician and their patients? One possible solution is compassion, which has subtle but important distinctions from empathy and sympathy. While sympathy says, “I feel for you” and suggests that one is feeling sorrow or pity for another at arm’s length, empathy says, “I feel with you” and connotates a deep understanding of another’s situation, such that one is feeling together with the other individual [22]. Compassion shares with empathy the elements of recognizing and relating to another’s pain and suffering, but differs by the presence of a reaction to this suffering and a desire to relieve it [22, 23]. Compassion says, “I’m with you and I hold you,” with an offering of tenderness, support, and encouragement that are needed for one to have the courage to take action to face these challenges in a way that is not draining, but rather maintains our well-being [24].

As such, compassion can serve as an antidote to empathic distress and fatigue. By providing compassion first to the provider (akin to a parent putting on their own oxygen mask prior to helping a child with theirs), they are able to attune to their own need for comfort and support that builds and fuels their own capacity to comfort and support another. In addition, by the same process in which one’s brain reacts to the experience of another’s pain via emotional resonance, so too does the same process occur for patients when a provider is able to attain, experience, and express inner kindness and calmness.

Did You Know?

The experience and practice of empathy versus compassion affect different networks of the brain. A study examining this found that empathy training was associated with activation of the insula and anterior middle cingulate cortex and increased reported negative affect and withdrawal. Conversely, compassion training was associated with activation of ventral striatum, medial orbitofrontal cortex, and nucleus accumbens, as well as increased reported positive affect and prosocial behavior [ 25 ] .

Consider the exercise “Giving and Receiving Compassion,” outlined in Fig. 15.10. This can be conducted as a formal meditation lasting 15–20 minutes, in which we consider an individual, such as a patient who is struggling or suffering and could benefit from compassion.

Fig. 15.10

Offering compassion to both the provider and patient . (Adapted from [7])

Skill-Building Exercise: Giving and Receiving Compassion

Case Scenario

Jack is an obstetrics and gynecology resident. He is working in a busy prenatal clinic and has follow-up with a patient who is now in her third trimester and nearing her delivery date. Jack has met with this patient before and found their previous interactions quite difficult. The patient is considered high-risk given her age and other comorbidities, and is highly anxious about delivery and the welfare of her baby.

During their encounter today, Jack notes that the patient remains highly anxious, voicing worry after worry, leading her to become tearful and distressed. Jack catches himself becoming distracted and disconnected from the encounter. Instead of distancing himself from the patient’s suffering and tuning out for the rest of the visit, solely offering education like he did previously, he tries focusing on his breath. With every inhalation he offers himself patience and compassion, and then begins to direct his exhalations to this patient offering her calm and kindness.

In doing so, Jack begins to notice his body relax and finds that he is able to feel more connected with the patient. He is able to listen more attentively to her concerns and experience not only empathy for her situation, but also compassion in which he actively wants to help ease her anxiety. Jack offers genuine and warm validation and support, and while there remains some uncertainty around the risks and outcomes of delivery, the patient also calms and feels reassured by Jack’s presence and approach.

Putting It into Practice

In this case, Jack was able to use the Giving and Receiving Compassion practice during an encounter with a patient who was suffering and overwhelmed. Consider giving this practice a try the next time you are in a difficult encounter with a patient or colleague, or even in a moment of quiet or solitude while considering a patient with whom there may be residual tension or countertransference.

For additional resources and guided meditations, the reader is directed to section “Additional Resources”, Table 15.2.

Another way in which compassion can be generated for both the physician and others (such as a patient or colleague) is through the practice of “Compassion with Equanimity” [7]. This can be particularly effective in coping with a caregiving situation that is stressful, exhausting, or frustrating. Consider, for instance, the patient with unexplained medical symptoms who repeatedly presents for care demanding a more intensive work-up, or the family member who becomes hostile and threatening as they disagree with their loved one’s care, or a colleague or supervisor who projects their anger onto another. In any of these cases, this exercise can help one to maintain calm and composure, to adaptively process the emotions and countertransference that may emerge, and to refrain from internalizing this experience as being suggestive of one’s own shortcomings or failures. It helps to compassionately recognize the suffering experienced by both parties and also provide a fair and realistic reminder of what is still within a provider’s capacity to do to help. Similar to the previous exercise, this practice can be conducted informally during challenging clinical encounters as outlined in Fig. 15.11, or more formally during an extended meditation, which can be found using the recommended resources in section “Additional Resources” (Table 15.2).

Fig. 15.11

Offering compassion with equanimity to both the provider and patient . (Adapted from [7])

Skill-Building Exercise: Compassion with Equanimity

Case Scenario

Ben is a family medicine graduate who is completing an extra year of training in emergency medicine with plans to work in a rural ER in the future. During one of his shifts, he meets a patient with opioid use disorder. After spending some time conducting an assessment, Ben learns that the patient had first began using pain killers after a car accident resulting in chronic myofascial pain. Over the years, however, they built up tolerance and began misusing the medications they had been prescribed, eventually leading them to purchase opioids off the street. This substance use has resulted in the patient losing their job and becoming estranged from their family. They ran out of money recently and as such could not afford to purchase these medications. The patient presented to the ER with the beginning signs of opioid withdrawal and is requesting a prescription for narcotics.

Ben listens attentively to the patient. He can see how uncomfortable and upset the patient is, and how addiction has ravaged their life, which he empathizes with. He advises the patient that he is unable to provide a prescription for narcotics, but instead he offers a variety of options and supports in lieu of this such as starting methadone or buprenorphine/naloxone, referral to a monitored detox unit or rehabilitation facility, or connections to other substance use programs in the community. The patient becomes increasingly upset by Ben’s refusal to provide a prescription and opts to leave the ER.

Ben is left feeling disheartened and deflated. He had previously worked in an addiction medicine clinic and is aware of how devastating addiction can be and how few resources there are to help those in need. The patient’s words and disappointment replay in his mind and he wonders whether he let this patient down and whether there was more he could have done. He notices this encounter greatly weighing on his conscience and decides to spend a few moments compassionately reflecting on this.

Ben spends a few moments centering himself using his breath. With every inhalation, he offers some kindness to himself, which helps to gently soften and soothe the recent uncomfortable memories, and with every exhalation, he works to release some of the tension he has been carrying. He then brings to mind the patient he just met with and directs some compassion with his outbreath to them. He reminds himself that he was just a moment in this patient’s life and that he is not at fault for this patient’s suffering. Ben reflects that he wishes he could have helped the patient and eased their struggles, but that sometimes it is not within his power to do so. He acknowledges that this was a difficult situation for both he and the patient, and in the future, he will continue to the best of his ability to help others when he can.

By spending a few moments engaging in this practice, Ben is able to diffuse the difficult emotions that had arisen, remind himself of what he is and isn’t capable of as a physician though he remains caring and empathetic to all patients he meets. He is able to refocus and move forward compassionately for the remainder of his shift.

Putting It into Practice

This is one example of how the “Compassion with Equanimity” practice can be put into place. As with Ben, this exercise can be done following a difficult encounter with a patient or a colleague, and can even be utilized in the moment. The next time you experience a challenging encounter that leads you to feel disempowered or to question your own abilities, consider trying out this practice.

For additional resources and guided meditations, the reader is directed to section “Additional Resources”, Table 15.2.

Self-Compassion in the Toughest Moments: Finding Silver Linings

There are challenging times that physicians face which can feel insurmountable. Perhaps this was a time in which, despite all the best efforts, the end result was not what had been hoped for or expected, or when failure was experienced, or when the obstacles standing in the way of a goal seemed too mountainous to overcome. Medicine can be a minefield of such barriers and experiences: the process of getting into medical school, the residency matching process, trying to meet all program and systems demands, attaining that “perfect” work-life integration as a staff physician, and trying to save and support every patient despite the odds. These experiences can feel defeating, and difficult emotions often linger long after the event, serving as unkind reminders and promoting the illusion that to attain this a provider must work harder, do better, and be stronger. Failing to succeed in these endeavours risks perpetuating self-blame and shame, and provoking negativity, cynicism and ultimately burnout.

So, the critical question is this: is there an alternative approach to help physicians better cope with such losses and obstacles? The answer, unsurprisingly, is again self-compassion. Compassion during these moments can work effectively to ease the resentment and shame that are often experienced during these difficult memories and situations. Being gentle and kind with the self opens the door for appreciation to enter. This in turn can offer a reminder of one’s strengths, promote gratitude for the hardships, and allow encouragement and motivation to be found, helping the individual to get up after they’ve fallen and try again.

One way to practice this is through the “Silver Linings” exercise [8], as outlined in Fig. 15.12. This exercise brings to mind situations, either from the past or those which one is currently facing, which feel overwhelming and nearly impossible to overcome. By exploring these experiences from both a self-critical and self-compassion lens, one will learn how judgment and resentment may fuel ongoing pessimism and hopelessness, while self-compassion can promote positivity, unearth valuable lessons learned during the hardship, and empower one to continue learning and growing.

Fig. 15.12

Diamond in the rough: Uncovering those hidden silver linings. (Adapted from [8])

Did You Know?

The #failforwardcampaign began in 2018 by Dr. Aleah Thompson, a family medicine resident, when she shared her own failures during medical training as a way to demonstrate to others that failure is in fact normal [ 26 ] . Her message serves as a powerful reminder that one is not defined by their failures, but rather by how they respond in the face of adversity. The campaign involved medical trainees and physicians sharing some of their failures, mistakes, or most difficult moments, but more importantly the stories of how they overcame these obstacles and used these as a catalyst to become better.

Rolling with Resistance: Troubleshooting Obstacles to the Practice

As with any lifestyle change or form of therapy/treatment, there can be challenges in applying new practices and behaviors and integrating them into one’s routine and daily life. For some, this may arise in the form of mental blocks or fixed beliefs, side effects, or negative reactions and experiences. For others, the obstacles may be related to environmental factors. Regardless of the cause, the key in overcoming these barriers involves first recognizing when they are present and impeding progress, and then engaging in problem-solving to address the root problem.

Self-compassion is no different. Though it may seem straightforward, requiring only a sense of self-awareness, commitment, patience, and practice, resistance can still rear its ugly head and interfere with the process and ultimately one’s personal and professional development. In this section, the common barriers to self-compassion interventions will be reviewed with suggestions to troubleshoot these difficulties.

“Who Needs Self-Compassion Anyways?”

The concept of self-compassion is unfortunately sometimes associated with negative connotations, such as being considered unnecessary or a sign of weakness [27]. These beliefs can be limiting, however, and can lead to avoidance of the practice entirely, its’ benefits being unfairly minimized, or stigmatizing of others who vocalize or practice the benefits of such approaches.

In response, how can such negative attributions be addressed? For the skeptics, it can be helpful to consider a time recently where you were facing a difficult or stressful situation or really struggling. If you are having a hard time bringing such an occasion to mind, imagine for instance one of these two scenarios:

• 1. One of your patients who you have known for some time and have been caring for over the past several weeks passes away. You experience grief and sadness over this, and wonder if there was something more you could have done to prolong their life. This is compounded when you learn that a complaint was lodged to the medical college by the patient’s family about the care that you had provided.

• 2. For several months you have been experiencing bullying by a colleague, involving repeated verbal put-downs. You have tried to address this with the individual directly, but this resulted in escalating shaming and ostracization, making your work environment a very uncomfortable and distressing place, and leading you to feel hopeless, particularly as you don’t feel safe disclosing this to others in the department and in seeking further support.

In all of these situations, real or imagined, you as the physician are experiencing significant stress, emotion, and pain, with no clear or immediate solution. The struggle is real, and so you reach out to a loved one or friend for a shoulder to lean on in your moment of suffering. Now, imagine this trusted individual offers one of two responses:

• 1. They are cold and uncaring, invalidating and minimizing of your experience. They might say something along the lines of “Well what did you expect? You knew what you were getting yourself into when you chose this profession. Just get over it! There are bigger problems going on in the world!”

• 2. They listen attentively to your story, and then offer warmth, validation, and understanding. They might say something like “I can’t imagine what this has been like for you, this must be so difficult. Is there anything I can do to help? Know that I am here for you anytime you need, I believe in you and know you’re a worthy person, a capable physician.”

Which individual would you want to speak to and would like to have in your corner during this difficult time? Looking at it from this perspective, the choice is likely clear, with a preference for having individual #2 coming alongside. Even though this individual may not be able to directly help us fix the problem, their attentiveness, kindness, and offering of genuine concern and empathy is meaningful. It provides a reminder that one is loved and worthy, and perhaps a sense of hope that one will eventually get through this.

So why then should the choice be any different when it comes to how one speaks to themselves? Just like one would choose the compassionate friend, one should also choose the compassionate self who helps to acknowledge our struggles and distress, and then offers kindness to enable adaptive coping, learning, and progression forward.

“Self-Compassion Will Not Motivate Me!”

For those of who have become accustomed to being tough on themselves, another barrier may be the belief that this toughness or strictness is vital to one’s intrinsic motivation and productivity. Without it, and should self-compassion replace this self-criticism, they believe they would become complacent, lazy, and unmotivated.

So how does one address this? Consider the concept of the “carrot vs. stick”. Imagine you have a mule, upon which you depend for transportation. There are two ways you could lead the mule in completing this work, either you beat it with a stick or you entice it with a carrot. Let’s explore this further:

• A. In the first scenario where you use the stick, though the mule may carry out the tasks that you demand, over time it becomes bruised and battered, and likely unhappy and tired. The stick, while motivating, is actually a punishment if they fail to do the job. In the future this risks task avoidance or becoming less efficient, causing a vicious cycle of escalating stress and physical toll.

• B. In the second scenario, the mule still achieves the goal, but it is fed, healthy, and happy. The carrot in this case serves as positive reinforcement, works to motivate and excite the mule, and perhaps keeps it focused and more productive.

Back to oneself now, considered in lieu of the mule, with self-criticism as the stick and self-compassion as the carrot, one can begin to see that self-compassion is motivating in a different and arguably a more adaptive and healthier way.

“Self-Compassion Sounds Exhausting; It Will Add to My Burnout!”

Physician work in healthcare is undeniably challenging . Physicians and medical trainees spend countless hours meeting with patients, actively listening to their concerns, completing various administrative tasks, and providing support, all to provide individuals and communities with the best care possible.

In this regard, empathy and commitment to care can lead physicians to dip deeply into their own resources and reserves such that they are able to meet system demands and go above and beyond for patients. Over time, and particularly if taxed beyond their means, physicians can end up feeling exhausted and depleted, ultimately placing them at risk for empathy fatigue and burnout. Once in this state, the idea of subsequently taking time to empathize with themselves in the practice of self-compassion and self-care may seem daunting and counterintuitive to restoring wellness. Some may wonder, won’t this practice require more effort and time overall, and so further the depths of exhaustion and burnout?

So how does one address this? Consider the idea that each individual has an internal tank, like that of a car, which represents their capacity to be well and to function both in our personal and professional life. Each day, just like a car when it is in use, the gas levels gradually decline as one exerts themself and goes about their various tasks and duties. In their roles as healthcare providers and educators, the effort invested in caring for others also leads these levels to decline, despite the fact that physicians and trainees may hopefully reap some meaning and satisfaction from doing so. Over time, if one does not stop to refuel, this can result in feeling drained and running on empty, which sets the stage for burnout .

One of the keys to addressing burnout is to ensure that one is regularly refilling their tanks. While this can come in different forms such as getting a good night’s sleep, or visiting with friends, self-compassion can also help to recharge and in this sense can be considered an antidote to burnout. Failure to engage in self-compassion means one’s tank continues to empty and the judgment and isolation one experiences as a result can lead the tanks to empty at a faster rate. In other words, self-compassion changes the way one relates to our challenges – so those same challenges (of residency, or otherwise) may stay the same, but they are not able to deplete with the same velocity or to the same depth or for as extended a time.

While no tool or practice to combat burnout should ever feel onerous, self-compassion offered in the right dose and adapted to an individual’s unique needs can in fact be one of the tools to mitigate burnout, helping to replenish and refill a physician’s tank to enable their own health and well-being while they care for others.

“It Does Not Feel Right, I Feel More Uncomfortable When Doing the Practices”

While engaging in self-compassion exercises or therapy, individuals may discover that in doing so they experience increased discomfort or distress. This is referred to as “backdraft.” Backdraft is a term originally coined by firefighters in describing the worsening or intensifying of a fire when a window or door is opened/broken down allowing oxygen to enter the space that’s ablaze [28].

When administering self-compassion or when in therapy, one’s heart (which has been tempered in the fire of all the hurts from the past) opens. Kindness, like oxygen, flows in. Similar to a real fire, this can trigger backdraft, as the kindness and openness can lead to re-experiencing old hurts, which results in worsening of the blaze and increasing feelings of pain or upset [7].

So how does one address this? Backdraft can be uncomfortable, but it should not be a feared part of this practice or of formal counseling or therapy. In fact, many who facilitate self-compassion programs consider it a healthy part of the therapeutic process and as a “compassionate exposure” [29]. In considering it with this lens, backdraft may help one to begin to recognize and process this former pain and anxiety, lessening their power to hurt and, in time, lessening their hold on one’s heart and mind.

Backdraft, however, can be overwhelming and can lead one to feel unsafe in the moment. As such it is helpful to be aware of it when it occurs and consider what is needed in that moment and what one is able to cope with at that time. As such, here are a few strategies to use when experiencing this phenomenon [7]:

• 1. Notice without judgment and let it be. Backdraft may dissipate on its own.

• 2. If the backdraft is particularly intense, reduce or step out from the practice you are engaged in. Consider returning to more brief and informal practices, slowly building up your capacity to experience this and tolerate the uncomfortable emotions.

• 3. Return to the basics of mindfulness and ground yourself in the present moment or engage in an activity you take pleasure in.

“I Cannot Seem to Get into the Routine”

As with most things, self-compassion is most effective when, if even just briefly, it is practiced consistently. It can be challenging, however, to get into the habit of self-compassion. This is not uncommon, particularly in medicine the default mode has been set toward finding faults, pointing out mistakes or shortcomings, and engaging in self-blame, particularly when worried, stressed, or struggling.

Consider the idea of a mental forest. The path of self-criticism has been well trodden for years, meaning that the walk is smooth and quick, although it does not always result in arrival at the desired destination. Self-compassion, however, offers us a new and more enjoyable place to visit, yet the path to get there, as it has not often been traveled upon, is unchartered territory which is overgrown and uneven. It may initially take longer to reach the desired destination using this new path; however, the more one takes this route, the smoother and quicker this path becomes. Meanwhile, the old path to selfcriticism begins to grow in, making it less accessible.

So how does one address this?

• 1. Be patient; though physicians have a tendency to strive toward the illusive ideal of “perfection” and quick mastery of skills, development of self-compassion can take time.

• 2. Start slow and be realistic about what you are able to integrate into your schedule. Perhaps start with more brief and informal practices, which only require a few moments of your time.

• 3. Set “SMART” (Specific, Measurable, Attainable, Relevant, and Timely) goals for yourself, aiming for a few minutes per day of practice.

Key Points

• There are several ways that resistance can arise when practicing self-compassion.

• Though resistance may seem to help in the short term, in the long term it can perpetuate suffering and lead to ongoing unhelpful behaviors and responses, such as avoidance.

• In encountering obstacles while practicing self-compassion, one question that may be helpful to explore is how self-criticism may help or hinder in comparison to self-compassion.

• Backdraft can be an overwhelming experience in which pain and distress can intensify as one invites in self-compassion. This is a normal part of the process and can be addressed either by acknowledgement or by toning down our practices for a time to better allow coping and adaptation.

Check Your Learning

Case Studies

Case I

Jeff is an internal medicine resident in his first year of training. In medical school he enjoyed his internal medicine rotations, particularly as he loved the wide variety of presentations and cases, as well as being directly involved in both acute crises and chronic disease management. He also really appreciated the abundance of teaching by staff and residents and has interests in pursuing medical education himself as he becomes more senior.

Now in his first year, Jeff has found the transition to residency to be more challenging than he anticipated. He is overwhelmed by the amount of material he feels he needs to know, particularly as he prepares to become a senior resident in a few months. He feels pressured by his seniors and preceptors, who frequently pimp him and challenge his medical reasoning, which amplifies the pressure Jeff already places on himself and intensifies his fears of making a mistake or the wrong decision.

During one call shift on his clinical teaching unit rotation, Jeff is asked to see a patient in the ER who appears to have congestive heart failure. He meets with the patient, conducts a thorough assessment, and feels confident in his management plan. While reviewing with the senior resident, however, they note some subtle abnormalities in the patient’s bloodwork that Jeff had not considered. The senior resident educates Jeff about this, advising him that this particular pattern of abnormalities can be suspicious for a form of leukemia; given this they should be conducting further investigations to rule this out. Jeff feels beside himself and is overwhelmed by guilt and sadness at having overlooked these findings.

• Question. How might Jeff handle this situation with a self-compassionate approach as opposed to a self-critical approach?

  • A. Jeff spends the rest of his call shift replaying the encounter in his mind, questioning himself and his abilities, and fixating on all the possible errors and ways he might have failed the patient.

  • B. Jeff recognizes that he is feeling overwhelmed and upset by the situation. He reflects that what he needs right now in order to stay focused and get through the next few hours are taking a few minutes to himself and going for a walk. He gives himself permission to take this time and heads to the cafeteria for a coffee. On the walk there he practices mindfulness by focusing on the soles of his feet.

  • C. Jeff takes some time to reflect on the struggle and stress that arose from this situation, recognizing that his reaction and emotions are normal and understandable given the circumstance. He also reminds himself that this was a difficult and advanced diagnosis to recognize especially at his level, and many other residents likely experience the same doubt when they feel they have made a mistake or have missed something. He thinks of what his partner may say to him, “that this was a tough situation, that we’re only human and can’t know everything.” Jeff reminds himself that he works very hard, cares deeply for his patients, and there is something he can learn from this situation going forward.

Answer: B and C ✔

While answer A may be the typical knee-jerk response for most medical trainees when such a situation arises, this is reflective of self-criticism. Likely this response would promote feelings of worthlessness and ineptitude and could eventually amount to Jeff experiencing shame as he suspects that no one else in his cohort would have made the same mistake.

Answers B and C however are more suggestive of a self-compassionate approach to the situation. In answer B, Jeff utilizes a combination of a “Self-Compassion Break” and the “Soles of the Feet” mindful grounding exercise in the moment. This helps to provide him with some mental distance from the event and to help diffuse and lessen the intense distressing emotions he experienced. By giving himself permission to take a quick break for a coffee, he demonstrates some kindness to himself and his needs, and maintains his focus and presence for the remainder of the shift.

Similarly, answer C demonstrates aspects of “Loving Kindness Moments,” “Silver Linings Exercise,” and the utility of considering a compassionate friend. While this response could be done in the moment, this could also be a helpful practice to engage in when Jeff has more time after his shift and if he notices the situation still weighing on him. Providing himself with self-compassion and processing the difficult emotions and thoughts related to the situation also create space for Jeff to be able to see this situation as a learning opportunity and part of his growth as a junior physician, rather than a personal failure. In choosing answer A, in many instances one can become “stuck” in self-criticism and miss the opportunity for learning and growth.

Case II

Lucy is a fourth-year psychiatry resident who has been spending the last few months working on a family health team. She has been closely following a patient in particular who is at high risk, given a history of impulsivity and several previous suicide attempts, with features of anxiety and borderline personality. While the patient has been fairly stable from a mental health standpoint with close ongoing support, Lucy has come to dread her encounters with this patient as they often spend at least an hour at each visit rehashing all of the patient’s current and ongoing stressors. Lucy finds the patient highly demanding, as she repeatedly and frequently requests medication changes and referrals for more intensive support, in which she subsequently fails to engage; yet, the patient ultimately blames Lucy for the ongoing struggles. Lucy meets with the patient again today. She feels drained and frustrated, and at a loss for how best to further support this patient, leading to feelings of worthlessness as a psychiatrist.

• Question. How might Lucy respond to this situation using self-compassion?

  • A. Tune out the patient as it is too exhausting and uncomfortable to share in their distress. They don’t listen to the solutions Lucy proposes anyways.

  • B. When noticing that she is turning away from the patient’s discomfort and finding it hard to validate, Lucy focuses on her breath directing her inhalations to herself and her exhalations to the patient, allowing her to stay calm and in the moment with the patient.

  • C. When noticing that she is experiencing countertransference and is feeling frustrated and as if she is unable to help with the patient’s suffering, Lucy reminds herself that moments like these are difficult and that although anger and distress may be directed toward her by the patient, she is not the cause of this patient’s suffering and it may not be entirely within her power to resolve this in spite of her hope to do so.

Answer: B and C ✔

Answer A occurs commonly when physicians or caregivers are experiencing empathic distress or fatigue. As it feels too much to bear, they distance themselves from the patient, are unable to provide empathy and validation, and focus instead on trying to fix things. This approach, however, can be invalidating and ineffective for the patient and leads physicians to feeling that their efforts are futile when they are rejected or appear to fail.

Answers B and C offer some suggestions for ways to handle this difficult situation using compassion for the self and to replenish Lucy’s own reserves so that she can continue providing care to her patient as well as compassion for the patient while maintaining Lucy’s attunement to the patient’s needs. “Giving and receiving compassion” using the breath (as demonstrated in answer B) can help Lucy stay present in the moment with the patient and can also serve through emotional resonance as a way for the patient to experience some calm and inner peace. In answer C, Lucy utilizes aspects of “Compassion with Equanimity” which helps to instill compassion and validation for the patient’s struggles, while also recognizing that this encounter can be challenging for the physician who may not always have the answers or the ability to resolve the patient’s pain and strife. It helps Lucy to refocus her efforts and allows her to be gentler with herself, reminding her what is within her power to change or help with, and allowing her to avoid internalizing such situations as failures.

Case III

Casey is a family medicine resident who heard about self-compassion from one of her preceptors. She became interested in the practice, as she had begun to recognize that she is highly critical of herself, which has had resultant impacts on her mood, self-esteem, and belief in her abilities, in addition to making it more difficult to connect with her patients and find enjoyment in her work.

To help guide her in developing self-compassion, she has begun utilizing audio- meditations online. Initially, Casey struggled during the meditations as she often found her mind would wander, but over time she was able to refrain from judging herself as harshly and learned how to bring her attention back to the moment. As she has progressed to deeper meditations such as providing loving kindness to herself and using self-compassion to address shame, she has encountered yet another obstacle. She now finds it hard to immerse herself in these meditations, particularly as she feels that they bring up more discomfort and anguish.

• Question 1. What is the form of resistance that Casey is experiencing?

  • A. Self-criticism

  • B. Disinterest

  • C. Backdraft

  • D. Depression

Answer: C ✔

This is an example of backdraft, which can be a normal part of engaging in self-compassion. As a fire intensifies when a door opens and oxygen enters in, so too does Casey’s discomfort escalate when she allows herself to experience kindness. Backdraft can come in different forms, either by precipitating tension or somatic symptoms, leading to heightened emotions like shame, grief, anger, or sadness, or by intensifying certain fears or thoughts of being a failure or being all alone. While backdraft can be confusing and catches Casey off guard, it is important to remember that this is a normal part of self-compassion and will lessen with ongoing practice. It may however signal that Casey needs to slow down the process and utilize self-compassion at her own pace, proceeding in a way which feels most comfortable.

• Question 2. How might Casey work to address this?

  • A. Challenge these feelings.

  • B. Notice it and let it pass.

  • C. Reduce or tone down her practice, focusing on more brief and informal practices until she feels better equipped to manage this.

  • D. Step out of the practice and engage in a relaxing, grounding, or enjoyable activity.

  • E. Give up on self-compassion.

Answer: B, C, and D ✔

As we know, Casey is experiencing backdraft. Though this may be off-putting and feel overwhelming, pushing Casey to battle against these feelings or to stop the practice of self-compassion altogether, it is important to remember that this is a normal experience and can be mitigated in different ways. For some, the backdraft can be tolerated and overcome simply by noticing it and sitting with it. For others, the backdraft can be so intense that they need to tone down their practices, returning to briefer exercises until building capacity to tolerate this. Alternatively, one can step out of the practice for a period of time to ground themselves before giving it another try.

• BONUS Question. How can one best maintain the skills and tools learned from self-compassion?

  • A. One and done – Once you’ve tried it once, no need to do it again!

  • B. Use periodically, whenever a significant stressor arises.

  • C. Practice regularly.

Answer: C ✔

As has been discussed in this chapter, for many who practice medicine, though empathetic and compassionate toward patients and others, it is often difficult to practice compassion for themselves. While this skill is innate within all human beings, it does require some practice to strengthen it, as does any other learned skill. It also takes time to replace the self-critical approach which often develops and becomes an automatic reflex during difficult or stressful times for many over much of their lifetime. As such, to get the most out of self-compassion and to maintain these tools and skills, it is recommended that one should practice these techniques, either formally or informally, on a regular basis.

Key Takeaways

• Self-compassion is one approach to promoting physician wellness.

  • As was reviewed in Chap. 2, self-compassion can be beneficial in several ways including reducing or mitigating physician burnout.

• Self-compassion is a practice that can be learned and developed. There are many interventions and exercises to develop and build self-compassion, including those that can quickly and easily be integrated into a busy day. It is important to remember that self-compassion does not have to be onerous or yet another task on the to-do list!

• While self-compassion can be helpful for just about anyone, it can be particularly useful for physicians and medical trainees who face tremendous stressors during training, as well as pressure and expectations to be invincible and superhuman. Self-compassion specifically aids physicians to be kind with themselves while maintaining connection with their patients, thereby helping to find a balance between both parties’ needs.

• Compassion not only confers kindness and validation, but also has an active component by fostering courage to face one’s challenges and promoting problem-solving and solution-finding to problems encountered. This allows for ongoing professional and personal development.

• Resistance is not uncommon to the practice of self-compassion. It is important to be mindful of this, as resistance can persist one’s suffering and maladaptive coping behaviors. There are many ways to tackle resistance. For those who experience backdraft, it can be helpful to know that this is a normal part of the process, but may signal the need to slow down compassion practices to build capacity to tolerate this.

Additional Resources

Additional resources regarding self-compassion exercises are illustrated in Table 15.2.