5 minute read
Wellness Committee: From Hero to Zero: Naiken, COVID-19, and Ways to Develop Empathy Despite Patients’ Challenging Life Choices
Andrew Grock, MD, Al’ai Alvarez, MD FAAEM, and Ilene Claudius, MD FAAEM
From dglaucomflecken on twitter:
2020
Working in the ED has always been difficult.
We do the best we can, the fastest we can, in order to help the most people that we can, regardless of their ability to pay, the severity of their illness, often while ignoring our own physical and emotional needs. On top of this stressful environment, we often bear the brunt of our patients’ anger and frustration at illness, at waits, or at stressors unrelated to our care. 1 Hence, much has been written on the limits and importance of physician empathy. Then the COVID-19 pandemic happened, placing us in the center of a passionate and often political debate. Heated conversations over vaccines and masking interrupt our provision of care, and we subject ourselves to the potential of direct harm from getting infected to care for patients who deny the very existence of the disease for which we treat them.
While caring for patients who make self-destructive decisions is not new to emergency medicine, the pandemic is different. The impact of COVID-19 on our daily lives has been overwhelming to many. Staff, families, and other patients are at risk of exposure. Patients coming in for other illnesses can wait longer for both emergency and definitive care because of COVID-19 overcrowding. There are conversations with patients demanding unproven therapeutics or those for which they don’t qualify. Worse, protesters are vilifying instead of appreciating the efforts of the medical community to prevent and treat Covid. In short, we’re exhausted, depleted, worse, feeling betrayed. Now, more than ever, we face an enormous gap in the amount of empathy we want to give and what little we have left.
While we can work to remedy this problem (strengthening our public health sector, educating our population, promoting societal leaders who defer to experts and promote truth over political capital, and crafting limitations that spread harmful misinformation on social media), we must also address our own struggles with burnout and decline in empathy. Several techniques have been described across a range of populations. This article will focus on one such technique known as Naiken.
Naikan is a Japanese introspection practice, which literally means “inner-looking” or “introspection.” It involves an examination of past deeds from both their own perspective and from the perspective of others. It consists of asking oneself the following three questions:
• What did I receive from this person?
• What did I return to this person?
• What troubles, worries, unhappiness did I cause this person? 3
More traditional Naikan practice consists of 15 hours of contemplation, divided into two-hourly periods. The participant engages in personal reflection on the three pre-set questions then reports thoughts back to a “guide” who listens and allows the participant to contemplate. While this time commitment may be unrealistic for many physicians and trainees, the essence of Naikan can be incorporated into meditation, debriefing, or wellness sessions.
The Naikan-based compassion training program emphasizes our interdependency with others and appreciating the kindness of others. Gratitude toward patients and sympathy for the pain that our long wait times, bad news, and other inconveniences we have caused them enable us to develop endearment and compassion for them. Improvements in interdependency and gratitude develop quickly and have been demonstrated in a short period of only one week of Naikan practice.
2021
The Naikan process also has a role in self-compassion by emphasizing healthy remorse for our omission, at times, to reciprocate kindness, patience, and forgiveness offered to us. 4 It is easy to focus on a few negative interactions during a shift. Still, by contemplating these Naikan questions, one can identify and acknowledge the multitude of ways that others have offered us their trust, gratitude, and patience. 5 We can see each other and the world around us more realistically. And the fact that we can never directly return these kindnesses provokes the desire to pass that goodwill along to others, which can help deepen the meaning and purpose we feel in our own lives. 4 When meaning and purpose find their way into one’s life, it can replace some of the focus on our own suffering. When compassion is engendered in oneself, it calms fear and self-protection and pacifies competitiveness.
The Dalai Lama describes compassion as “an openness to the suffering of others with a commitment to relieve it.” While we cannot simply “compassion” our way into all the challenges we encounter in healthcare, many of which are systems-driven inefficiencies beyond our control, the Naikan philosophy offers an opportunity for us to remain open and committed despite many challenges. Choosing compassion is within our control.
References
UCLA Emergency Medicine Department, @AndyGrock
Director of Well-Being, Stanford Emergency Medicine, @alvarezzzy
Director of Quality Improvement, Harbor-UCLA Medical Center
1. Lall MD, Bilimoria KY, Lu DW, et al. Prevalence of Discrimination, Abuse, and Harassment in Emergency Medicine Residency Training in the US. JAMA Netw Open. 2021;4(8):e2121706.
2. Bergwerk M, Gonen T, Lustig Y, et al. Covid-19 Breakthrough Infections in Vaccinated Health Care Workers. N Engl J Med. 2021;0(0):null.
3. Naikan. In: Wikipedia. ; 2021.
4. Hedstrom LJ. Morita and Naikan therapies: American applications.
Psychother Theory Res Pract Train. 1994;31(1):154-160. 5. Krech G. Naikan: Gratitude, Grace, and the Japanese Art of Self-
6. Goleman D and Davidson RJ. Altered Traits : Science Reveals How Meditation Changes Your Mind, Brain, and Body. New York, NY: Avery, an imprint of Penguin Random House; 2018.
