Empathy Fatigue With Dr. Ethan Kunstadt



Empathy Fatigue is a very real side effect of the COVID-19 pandemic, and it’s critically impacting our health care professionals. Clinicians have been reporting more difficulty with empathy and compassion in the years since the beginning of the pandemic. How are we going to respond to this challenge? Dr. Alaina Rajagopal features Dr. Ethan Kunstadt, an emergency medicine physician in Orange County, California. They explore two articles which highlight some of these issues, as well as strategies for coping, fighting misinformation, and moving forward.


References:

Sohn, Emily. 2021. Empathy fatigue in clinicians rises with latest COVID-19 surge. Medscape. Published Sept 16, 2021. https://www.medscape.com/viewarticle/958890

Russell, Peter. 2022. Healthcare workers ‘most likely to report long COVID symptoms.’ Medscape. Published Jan 6, 2022. https://www.medscape.co.uk/viewarticle/healthcare-workers-most-likely-report-long-covid-symptoms-2022a10001dt

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Empathy Fatigue With Dr. Ethan Kunstadt


We're talking to Dr. Ethan Kunstadt. He graduated with a BS in Neuroscience from the University of Miami. He went to Medical School at the University of Alabama School of Medicine and then went to a residency at the University of California, Irvine. He practices Emergency Medicine in Orange County, California. Welcome, Dr. Kunstadt.


Thanks for having me. I appreciate it. This is my first show, so it’s very much an honor and a pleasure to be here with you.


This episode is going to focus on COVID-19 fatigue and empathy fatigue. What is COVID-19 fatigue, you may ask? There's the medical definition of real fatigue that one might experience after getting COVID-19 but we're going to talk about the more philosophical sense. The fatigue that we all have after having dealt with COVID-19 for several years. That cringing feeling that occurs when you hear the word COVID-19 or outrightly shutting down conversations involving COVID-19 and maybe even pretending it doesn't exist at all. Before we get into all that, tell me a little bit about your background. When did you know you wanted to be a doctor?


I grew up in Mobile, Alabama. I was a candy striper when I was pretty young. I don't hear that term anymore. I don't know if they still use it but I was volunteering in the hospital. My parents had a friend who was an emergency medicine physician in Mobile and long story short, I began shadowing with him probably when I was about 14 or 15 and loved it from the get-go. It stuck with that through school and medical school.


What were you doing as a candy striper?


It was when I was probably 13 or 14. There’s pushing people in the hallways and nothing important. It was the emergency medicine shadowing when I found out that I'm going to do medicine.


Tell me more about that. When did you choose and what made you choose emergency medicine?


I was 14 years old and I had stitches in my back that needed to be removed. My parents said, “We'll bring you to this physician who's our friend in the ER. He'll remove them.” After that, he's like, “Let me show you around the ER for a bit.” We walked around and saw all these things happening. The alarms went off and there was a lot of excitement. I like the energy of it.


The variability I was seeing in that one day, walking throughout the ER. He said, “Come back, shadow me some time.” I did that pretty regularly throughout high school. Times are different then. I remember the quick paper charts and people putting OG tubes in for alcohol intoxication. It was a different time for sure. It was intense. I distinctly have a vivid photographic memory of this patient that was hating it. It's funny to look back at it. We give them Zofran and watch them.


Emergency medicine is something that you've known you wanted to go into for some time. Did you ever consider any other specialties or was it emergency medicine 100% from the start?


It was pretty much emergency medicine from the start. When I went through clinical and third-year medical school, OB-GYN caught my eye for a little bit because of the procedures and the medicine that they practice. I like surgery a little bit because of procedures but that lifestyle was on for me. Ultimately, emergency medicine was what I wanted to do and I stuck with that in most of the medical school.


What's your favorite thing about emergency medicine?


The variability. Not knowing what's going to happen and everyone says that but it is exciting to go to work. It's a little bit unsettling as well but you don't know what's going to happen. It's going to be mostly COVID, unfortunately, but every single day is something different and something we can learn from.


Speaking of COVID, how have you been affected by the pandemic?


In many different ways that a lot of us, whether we're in medicine or not, are affected. You and I have finished residency not long before all of this. I don't think we thought a year or so out from residency that we'd be in the middle of this pandemic that is going on several years that we're still in the middle of. It's tough.


You're hearing all these different opinions from different people, not always knowing who to trust, what to think and your home life. Some people have families that have to bring it home to and loved ones that they're scared to infect. They can't see them for a prolonged period. The surge happens and you don't want to see your family. It goes on and on.


That's a constant worry for me as well, where I don't want to bring it home to my family. That's been the scariest part. We have vaccines, so I feel much safer doing the work in the emergency department but we don't have vaccines for kids under five. I worry about that.


Having a family at home, a young unvaccinated kid or maybe some elderly that, even as vaccinated, we still worried about is a challenge. On the contrary, I live alone. You come home and no one's there to infect but then there's no one to decompress and talk to you about what's going on at work. It's both sides.


One of the main topics for this episode is talking about how physicians decompress or don't decompress. Let's get into that. We're planning to talk about COVID fatigue and empathy fatigue. You found an interesting article on empathy fatigue published by Emily Sohn on Medscape. In the article, Dr. Kaz Nelson states that compassion fatigue or empathy fatigue is one reaction to feeling completely maxed out and overstressed. Anger in society is another response. As clinicians, empathy is a critical aspect of the care that we provide. How did you view clinical empathy prior to the pandemic compared to several years into the pandemic?


Empathy Fatigue: Even though Omicron is not as severe a variant, it seems that you could still get on COVID from less severe cases.

It’s a lot different, unfortunately. It's been harder to do, mostly because of fatigue but it's certainly a cornerstone of what we do. If you can't understand the patient in front of you, it's difficult to provide effective care. It's the fatigue and empathy is one of these things that slips away as you get more exhausted. It requires a lot of energy. When that is wearing thin and we're moving quickly in a stressful environment, that's something that a lot of us can start to forget about.


You'll see that a lot in residents as well. There's been quite a bit of research published on medical students having very empathetic approaches to patients and very excited about medicine. Somehow during the process of residency, physicians tend to lose some of that empathy or experience more of this empathy fatigue. It's not new to COVID. It happens anytime to somebody who is overworked or burned out. The pandemic highlight a lot of those issues.


By medical school and residency, you've done 7, 8 to 9 years of exhausting training where you feel like sometimes you're not appreciated and the hard work that you're providing isn't good enough. Over time, that chips away at you. Maybe it's partially our own doing and the rigorousness of the medical training system in general but it can see people in residency in the end and how they changed. It's unfortunate and COVID is only going to make that worse. I don't know if it's the emergency department alone where it's a pretty jaded environment and empathy might slip up even more but certainly, you see it amongst other specialties as well.


We've seen a lot of clinicians, doctors, nurses and techs post videos on social media, completely emotionally overwhelmed, frustrated, feeling helpless and hopeless. There are a lot of different mechanisms people use to cope from going through the motions or completely dissociating and viewing patients from a distance lens or maybe even not as a human. What coping mechanisms have you observed in the emergency department or on social media over the last couple of years?


There are a lot of social media posts about frustrations and exhaustion. People want to voice what they're feeling and people feel bad for that way. A natural way to move on from something is to talk about what you're feeling. It's interesting to think about how this pandemic would have played out if social media didn't exist and that's a whole separate discussion. In a way, it's good. It allows people to have a voice may be that they wouldn't have to people where they can express how they're feeling and other times, it can be not beneficial. It can cause unrest and uncertainty.


We did an episode a while back with Dr. Sander van der Linden, who studies misinformation and particularly misinformation as it's proliferated on social media. It's a topic that needs a lot more research but we've seen in medicine, in particular, how much misinformation can affect patient care and empathy fatigue in physicians.


You work hard all day around COVID. You come home, log on to some social media and then see someone bashing what you're doing or the approach that you're taking. It's frustrating because there's a lack of control in that. I don't have a decision about how we're treating COVID. I'm doing what we're told is the best thing to do based on the evidence that we have but how do you reconcile working all day long and seeing it firsthand with a post saying it's not that bad or real? It's very stressful and hard to overcome.


In emergency medicine, in particular, we get used to seeing terrible things and moving on from them quickly. In an episode, we discussed how most people could do this to a certain extent but then you reached a critical point when there isn't enough of a break between those episodes of terrible things. People get overwhelmed because there's no time to recover. Do you feel like you were prepared to cope with the pandemic because of your training in emergency medicine?


To some degree in emergency medicine, as a provider, you have to compartmentalize things or at least that's how it seems. I don't think you can provide sympathy or empathy to every patient when they're going through a hard time, as you would, maybe a loved one in that situation because you don't have the energy for that.


You could not do the job if that level of sympathy or empathy was provided to every patient every day. That doesn't mean that you can't come across, that you've emphasized the best with them but in terms of how you're feeling at that moment, I do feel this sense of dissociating at times, where you have six patients to see and they all don't want to be there. You have to go room to room and talk to them about what's going on. Provide compassion and with the mask on when they can't see your face. It's easy to get into this cycle of running through it. I don't know if I de-humanize the patient but certainly, you disconnect to make the job easier.


You brought up a couple of good points, particularly with the mask. Having all of the PPE, the mask can be a shield and patients can't see our face. It's much more difficult to convey empathy and compassion through your facial expressions when people can't see your face and you can't see their face. That in and of itself probably leads to a lot of this empathy fatigue because you don't get that feedback. You don't know that someone's understanding that you are trying to empathize with them.


You also bring up a good point in that you can take every patient home with you, not in the literal sense but a figurative sense. At some point, you have to find a way to dissociate and detach so you can go home, continue to live a normal life and not be debilitated sometimes by terrible things that we see or the horrible stories that we remember.


Even at the beginning of being out of residency and being on my own, I would start to have this pattern of bringing stuff home with me mentally. Run your cases again and think about, “Do I this or that wrong?” I was worn down. I could not continue doing that. I had to consciously make an effort to leave work and try to not even start that thought process because once it started, I couldn't stop it.


Try to keep everything at work, not running cases over again, in my mind. With a mask thing, I feel I've certainly done a lot more sitting down at the bedside, a lot more hand on shoulders, other ways to show it. You are lacking a lot with your face being covered in terms of showing compassion with the patient there.


In the article, Dr. Mona Massoud stated, “It's hard to have empathy for very self-centered people. We're at a place where we're having to choose between self-preservation and empathy.” That's a lot to unload there.


A lot of the focus in this article is about seeing patients who aren't vaccinated to come in and looking at that patient, that's preventable, which is by and large very true but as we're going through the Omicron surge and you're seeing people come in that are vaccinated, they have COVID, frustrated and are mostly mildly sick, it is moving on from people that are vaccinated to everybody with COVID are all sick. Before COVID, we treated patients that would always have bad behaviors at home that would hurt them. We didn't seem to hold it against them necessarily and maybe it's the sheer number that's causing the frustration. A diabetic who continues to drink Coke in the waiting room, it happens again.


The stage four lung cancer who continues to smoke or the extreme athlete who's broken pretty much every bone in their body, then they continue to go back out there and do more. We're used to seeing patients who don't necessarily make the best decisions for their health and care. The point that you brought up is critical why we're seeing so much more of this empathy fatigue. Those cases that we talked about are fairly rare, except for maybe diabetes. We see that pretty often but part of what's been so hard about COVID is that many providers haven't had time to recover their empathy before they have to see another case and that can lead them to feel helpless.


One of the ways that we are protected in emergency medicine is that a lot of us don't work a ton of shifts relative to other physicians. I worked full-time, 12 to 13 shifts a month and more than ever, I try to make the best use of my off time because the next shifts might be mentally or physically exhausting. I need to decompress. We all need to do that. It's difficult if you're busy life at home with family and kids but we need to be consciously aware of the stress that we're having, identify that and then find ways to counteract that when we cannot be at work.


As clinicians who have gone through all of those years of training, we aren't necessarily the best at identifying what we need to do for self-care. The pandemic has highlighted some of those issues, where when people are not at work, there has to be a way to decompress and rehabilitate yourself and your mental state so that you can go back to work ready with that empathy and compassion.


One thing that doctors have reported as stressful in this article is the number of critically ill young people they've seen, the unvaccinated patients who request vaccination after it's too late because they’re about to be intubated and the patients with COVID who request medications like Ivermectin and hydroxy-chloroquine but refuse vaccination.


I find the last point paradoxical. It's hard for me to understand why patients request medications that are useless at best and harmful at worst. They think that vaccines are dangerous. Dr. Heidi Erickson states that she's frustrated, not by individual patients but by a system that has allowed misinformation to proliferate. I tend to agree with that sentiment. This frustration can then lead to more of the burnout and empathy fatigue that we're talking about. What pieces of misinformation have you encountered frequently or want to debunk?


It's all the things that we continue to hear, “The vaccines have side effects. I'm not going to be able to have kids one day. I need to Ivermectin or hydroxychloroquine.” All these things come up day in and day out where I work. Honestly, at this point, I blow them off. I don't have the time for each patient to explain that they're being fed misinformation.


At the same time, to say that we're frustrated by people asking are these things is showing a lack of empathy, that we don't understand how they could feel or think this way. In reality, it's a product of what they're being given and shown on whatever media outlets. We have to understand that. We can blame the patient.


That's easy to do but there’s a product of a problem that is a much deeper seed. We have to understand that. We can try to explain to them that the wrong in a diabetic manner, which can be hard in a very impassioned patient but we also need to understand where it's coming from. That's potentially more important.


Dr. van der Linden had some good strategies for trying to get to the basis of misinformation. He'd suggested asking a patient what their understanding is. It’s asking questions to try to figure out where the information is coming from and what they're willing to hear because if they are willing to hear anything, the conversation probably isn't going to be effective. Unfortunately, asking a lot of questions is something we don't necessarily always have time for in the emergency department. Sometimes these conversations don't happen as often as they should but it’s something good to keep in mind whenever we come across these types of issues.


Also, once people hear something, it’s much harder to get them done hear it. You already have a losing battle ahead of you and with a short amount of time when they've spent who knows how many hours at home bored Googling things in a rabbit hole of information. You got to be effective if you're going to try to address these things in the ER or a clinical setting but it's incredibly hard. I have found it in the past and I try it, which is why I almost don't try as much anymore because I feel like I don't get somewhere that I want to get with a patient in an amount of time but people need to try. We need to find the best way to do it. The first way is to remove that initial misinformation probably.


People choose what information to believe and not believe. Potentially, if you hear that something is incorrect, enough times, it might help turn the tables in one direction versus the other. Hopefully, the side of truth, logic and signs but there is a lot of misinformation out there. Sometimes it does feel like a losing battle.


There's one article that you and I discussed, a second article surrounding long COVID. It was reported by Medscape that healthcare workers are in the top three groups to report symptoms of long COVID. We did an episode on long COVID previously but could you briefly tell us a little bit about what long COVID is?


There's not one formal definition or diagnostic criteria but according to the CDC, long COVID or post COVID conditions are a wide range of new returning or ongoing health problems people can experience four or more weeks after first being infected with the virus that causes COVID.


It looked like this article reported the most common symptom was feeling weak or tired. That was reported by over half of the survey participants. They also reported a loss of smell, shortness of breath, muscle aches, sleep problems and difficulty concentrating. Based on those symptoms, every healthcare worker had long COVID before COVID ever existed. What were the other groups in the top three besides healthcare workers?


Despite the articles, title characters were the third, most likely to have the long COVID. The first was social care workers, which are social workers. The second were teachers and the third were healthcare workers.


I thought that title was a little misleading as well.


It says most likely are up to providers when it says that we’re third, which is still not good but not the most.


It's also important to note that these data are from the time of the Delta variant, not from Omicron. It may be different with the different variants but it’s hard to say.


At first, we think that this long COVID could be a sequel to severe COVID illness like people that are in ICU and ventilators. Those people get de-conditioned and they have post ICU syndrome, which is just that. A lot of people that have mild symptoms that are never hospitalized go on to have long COVID. We could be seeing a surge after Omicron. Even though it's not as severe as a variant seems, it seems that you can still get on COVID from a less severe case.


Empathy Fatigue: If we can't think of a system or have enough good tests to hand out to people in this country, and we can't figure out who actually has COVID, how are we going to get over this thing?

Some people with long COVID never even experienced symptoms from their initial infection. You can be completely asymptomatic with your initial infection and then, weeks later, start to experience chest pain, shortness of breath, fatigue or any number of those other symptoms. That's something that's been misleading and not well discussed in the media. If you don't end up hospitalized or you don't die from COVID, there are still a lot of other concerning issues that can happen.


If I were to have gone on to have chronic shortness of breath, my life would be impacted significantly. Everything I like doing, I wouldn't be able to do or look not to the same level. Oddly, people are having these symptoms despite having maybe no symptoms. Its physiology of it is odd. I thought that several years into this thing, we'd have more evidence on this long COVID because I haven't revisited this in a while until I look back at UpToDate and other sources for long COVID information but there's not a lot on it. They tell you the symptoms and they say, “You can prefer someone to cardiologists or pulmonologists,” but they don't know much. Hopefully, we're still learning about it but there's a lot to learn.


Episodes ago, we spoke with the Head of Long COVID Kids, an organization that was created to help support kids who are suffering from long COVID. She said the same thing that there's not a lot of information out there and parents don't know where to go for resources. There are not a lot of clinicians who are specialized in treating these types of disorders. It's something we can learn about like COVID itself.


If we don't have unified diagnostic criteria to define it, you can't even diagnose it. How are you going to start treating it? The first thing is we need to have, what are the criteria to say? You have long COVID, not just that you have fatigue after being in the ICU for 1 or 2 months but we need to figure out what it is and then put people into these categories of having or not. We can study them more closely. It's difficult because a lot of it's subjective stuff. Are you going to do PMTs or Pulmonary Function Tests in people that report shortness of breath or are you saying anybody that reports shortness of breath three months from a COVID infection has long COVID? There's a lot of different ways to look at it.


Dr. David Strain, who is a senior clinical lecturer at the University of Exeter, had an interesting perspective. In the article, he said, “As we continue to see case numbers of Omicron rise, we must be wary that our reliance purely on hospitalizations and death as a measure of the risk from COVID could grossly underestimate the public health impact of our current COVID strategy.” I thought this was interesting. We do tend to focus so much on mortality and hospitalizations but we rarely discussed the impacts of problems like long COVID and invested in the infrastructure and learning, understanding and defining it.


Initially, in a pandemic with a virus, we don't know you're going to focus on death in hospitals. It makes the most sense but we are seeing so many other ways to be affected by this. Whether it's long COVID, getting COVID the second time, being out of work and then losing work from it. More people are in the waiting room during busy hours for non-COVID symptoms or things that are critical that are getting delays in treatment because the ERs are overrun with COVID cases. There's a lot of different measures that we need to look at that can affect people directly or indirectly.


What is one thing you wish everyone knew about COVID-19?


It's an incredibly complex virus. We've never seen anything like this in the last hundred years or so and it's still going on around. At times, it feels like we're in the same place we work at the beginning of 2020. It's a potentially deadly virus but the vaccinated people are going to be okay. There's a lot of hysteria that you can give into. There will be different media outlets.

We're all at a point in our mind where we're stressed out and tired of this but the worst thing you can do is to get more bogged down in the hysteria and constant news about how bad it is. Do what you can to protect yourself. Get vaccinated, be healthy, take care of yourself and your loved ones. Eventually, this will hopefully move on.


It's so hard to balance the hysteria with the apathy. We're suffering from both where there's still this mass media cycle of constant discussion about how horrible things are but there's also this growing apathy where people have gotten so tired and fed up at this point. They have the approach of, “I don't care. Whatever happens, happens. I'm going to do what I want.”


You're seeing articles or headlines saying, “We're going to move on and live at this point.” That's an interesting approach. Some countries will try that to some degree but we got to stop watching the news. I go to my parents' house. The news is on at 6:00. At 7:00, it's the same story. It feeds into this fear. A lot of the current surge in Omicron where we're seeing ER overrun with people with COVID have mostly mild symptoms.


It's like, “I'm scared I have COVID. I need to go to the ER. I'm not going to die.” I don't blame that. I, fortunately, did not get COVID, which is incredible at this point but if I got COVID, I would start being a little bit worried. I know what could happen to me. If you're a late person that gets COVID and all you hear is that you're in a die from it all day, maybe you're going to go to the ER to get checked out.


A lot of times, some patients are negative for COVID but come to the ER for testing because they know they've been exposed. By being in the emergency department, they potentially get exposed again. I wish that there was a way to help monitor the media cycle. If you think about many years ago, there was one news program a day and everybody watched whatever channel they were going to watch but it was on one time a day. Now, there's a 24-hour news cycle.


There's pressure for the media to report something new or keep reporting on something continuously. Some of that could have contributed to some of the hysteria that you were mentioning.


That's financially driven, I'm sure. They want to sell stories and want the TV on their channel. You have to understand that context as well but we limit how much we consume at this point.


What is a lesson you think we can take from this pandemic to prepare for future outbreaks and hopefully not more handout mix but just in case?


That's a lot of things but one thing, in particular, that we still haven't gotten right is testing. You see many people and if you alluded to it, people test negative for the virus when they have COVID. They feel falsely reassured. They go on to go out that night and spread it to other people. I continually see people that test negative and have COVID.


If we can't think of a system or have enough good tests to hand out to people in this country and we can't figure out who has COVID, how are we going to get over this thing? How are we going to have people isolated appropriately or not? That is one of the more frustrating things to see people come into the ER for maybe confirmation tests. Maybe they need it because if your roommate has COVID and you have a cough, shortness of breath and you test negative on your home COVID tests, you probably have COVID but not everyone thinks that.


There are a lot of patients that I've seen where I think, “This one for sure has COVID.” They test negative. I'm like, “I don't believe that. Maybe the swab wasn't high enough and there is probably a false negative.” Thinking about that, understanding positive predictive values and negative predictive values, false positives and false negatives.


We go to medical school and I went to grad school before medical school. Those are difficult concepts sometimes to fully understand and how different tests have different abilities to find the disease at different times during that disease. That's unclear to the general public too. Maybe we should do an episode on that in the future.


The different tests have different periods. They're going to be positive during the time course of the virus. People don't know this stuff and they need to know because otherwise, they're going to have a false negative and not know it.


Any final thoughts or anything else you'd like to share before we wrap up this episode?


Thanks for having me. I appreciate it. These kinds of discussions need to be had and occur more frequently in regards to everything but also COVID in particular. There's a lot of news swirling on around out there and you can get your information from different places. There is a lot of frustration when people think different ways but maybe if we can have a civil discussion about how we feel about things, we can get over this a little bit sooner.


Thank you so much for joining us. We appreciate your input and all of the research that you did for this. That's it for this episode. If you like what you read, please subscribe, comment, like or send this episode to someone who might need to know it. This episode was supported by the National Geographic Society Emergency Fund For Journalists.


Thanks for reading.


Until next time.


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