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As COVID-19 vaccines become available to more age groups, will fatigue from the pandemic subside? Or will it create a greater disconnect between the healthcare workers struggling to provide consistent and compassionate care, and the people sick with COVID who need treatment due to resistance to protective health measures?

Oftentimes, it can feel like you’re doing all the right things — getting vaccinated, wearing masks, social distancing — while others are opting out, which can lead to compassion fatigue, a mental health condition that differs from burnout, and is hitting those on the front lines the hardest.

On this week’s episode, Jessica Gold, MD, MS, of the department of psychiatry at Washington University School of Medicine in St. Louis, joins us to explain how healthcare professionals can move past the fatigue and care for themselves.

The following is an abridged transcript of her interview with “Track the Vax” host, Serena Marshall:

Marshall: So it really seems like healthcare workers are the ones bearing the brunt of this pandemic.

Gold: Yeah. I mean, I appreciate you even asking about them. I think that sometimes they’re a forgotten group. I know that they’re the majority of your listeners, but I think as a group in general, healthcare workers just keep working and feel forgotten. I think they keep going to work every day and doing what they’re supposed to do. And what they’re supposed to do is bear the brunt of the pandemic, right?

And having to see what they’ve seen and honestly have mental health problems before the pandemic, which is not something new, and then go into the pandemic where they’re exposed to a really new environment with a lot of death, a lot of emotional toll, risk to themselves.

And then have these little moments of possibly having hope and then it just keeps going. And I think that’s just been the case for healthcare workers this whole time. And as a healthcare worker who sees healthcare workers, it’s definitely been hard on everybody.

Marshall: Let’s look at first — before we dive into this a little deeper — the differences though. Because people might hear this and be like, “oh, they’re just burnt out. They’ve just been working a lot.” But there’s a difference between burnout and compassion fatigue, right?

Gold: Yeah, we use a lot of terms. I was just talking to someone [who was] also like, where do mental health and wellness fit in here? And I think that we just throw a lot of terms around, it makes it really confusing for people. So my attempt to break this down would be, if you think about compassion fatigue, that’s really like the cost of caring for people.

It includes burnout. That’s actually part of compassion fatigue, but there’s also this part where you’re exposed to trauma. Like what you do every day at work is exposing you to trauma and you’re taking that on, and that doesn’t have to happen for burnout. So, with burnout, you just have this kind of constellation of three things that we typically think of, which is you have depersonalization. So we often think of that as treating patients like objects. A reduced sense of personal accomplishment, so you’re not getting as much done. You might be getting told you’re not getting as much done. And emotional exhaustion, which is what people often think about. And that always has to do with work.

So, it’s always about the work environment. It could be any work environment. And then when you think about compassion fatigue, those are specific to work environments where you can actually be exposed to people who are suffering. And that’s what healthcare workers do. They take on the suffering of the people that they’re caring for, because there’s only really so much you can hold.

And I think empathetic people go into healthcare and then exposure to really hard stories after really hard stories that get you identifying with the patients and you end up feeling like it’s just like a lot of trauma that you get yourself. Both of those things then are different from mental health conditions, which I think depression would be the most logical one that fits in there. And depression has some of the same symptoms. Again, because with emotional exhaustion, you might see fatigue or insomnia, but you also won’t necessarily see a depressed mood, change in appetite, actual change in interest in things, or, of course, the more serious kinds of symptoms, like suicidal thoughts.

So, it’s kind of a spectrum. And burnout can lead to depression, and compassion fatigue is sort of a more acute form of that mental health [condition], like what you’re experiencing by working in healthcare, but it’s a big spectrum that we can experience by working in healthcare.

Marshall: Okay. So it sounds like there’s a lot of overlap. So how would you know if you’re experiencing compassion fatigue or burnout? Is there a metric that you can look at to determine if it’s one or the other?

Gold: I wouldn’t necessarily say, I’m sure that there are metrics online and there are different tests that you can take and different measures that people have made for burnout or compassion fatigue alone, which they use in studies. I think the biggest thing really is the acuity by which it comes on.

So, as a healthcare worker, because you’re in a field where you can be exposed to secondary trauma, you can be exposed to compassion fatigue and burnout, so that makes it like, you know, right off the bat, you can have either. But burnout typically is something that comes out over time, and compassion fatigue tends to be something that you see much quicker. It tends to be a more sudden onset, tends to be even shorter-lived. And typically people view it as a bit easier to manage than burnout, but they have some similar signs. And I think that that makes it hard for people to necessarily know the difference.

But you might see with compassion fatigue more of those signs of trauma than you would see with burnout. So, you could see things like feeling emotionally disconnected, feeling like you’re having more psychological distress around people, feeling more activated, feeling unable to actually see certain types of patients, feeling more irritable. And a lot of those kinds of things that you experience with post-traumatic stress, so you might see nightmares, you might see people having flashbacks, and those kinds of things you wouldn’t see with burnout because it’s not involved in a traumatic reaction.

Marshall: Now, we’ve mentioned a lot about how healthcare workers are feeling the brunt of this, but those definitions could be expanded to others who are caring for individuals, policy makers, teachers, those who generally perhaps care about societal public health?

Gold: Oh, absolutely. And anybody who’s a caregiver. So mothers, people who are caring for sick people at home. I think we don’t necessarily think about all of these populations who are taking care of others. And it’s a very big group of people. You know, advocacy is a very hard career particularly now. And when you’re an advocate, you often have to repeatedly tell your personal story and that can feel traumatic at times. And I think you often also have to listen to people’s stories because people feel connected to you and they tell you their story. And that’s another field that I can think of kind of off the top of my head.

Marshall: So as more options become available to lessen the strain and the impact on those frontline workers, do we expect this compassion fatigue to lessen, or is it going to become more acute because those who now are getting sick are the ones who have pushed back on those public health measures strongest?

Gold: I mean, I think we’re seeing more compassion fatigue right now. I think what I’ve been seeing in patients went from people kind of saying this career is hard, but I signed up for it and I’m ready to help, to it doesn’t have to be this way, to I just don’t want to do this and I don’t want to be here doing this job.

And that kind of expression is a really different expression than I’ve heard in patients. I think people don’t feel as comfortable being around patients who don’t necessarily have to be in the hospital because they could have done one thing to keep themselves out of the hospital …

Marshall: And that one thing we’re talking about is …

Gold: Getting a vaccine.

Marshall: Yes.

Gold: And I think when you’re in that situation and you’re seeing people who are really sick because of that or family members who are sick because of that, or you’re in a situation where you have a person admitted for an entirely different reason, and your job is to try to convince them to then get vaccinated because they’re in the hospital, those conversations are really just challenging because you’re still having them.

You’re still putting yourself at risk and your family at risk by doing your job every day. And it seems like a very simple thing to have people do. At the beginning, it felt like masks maybe were not as obvious and we didn’t have as much evidence right at the beginning, or social distancing felt like a lot to ask people, maybe, but this feels like they’re paying for it. It works. We know it works. It’s been working in a lot of people. We have a lot of evidence. And so I think it just gets really hard, and they don’t really want to have those conversations, but of course at the same time they keep doing their jobs because that’s what we do.

Marshall: I mean, it really sounds like what you’re hearing from the providers is that it’s almost hard to have the compassion for the unvaccinated. And so how do you dance that line?

Gold: I mean, I’ve been having a lot of conversations about how emotions are OK. And just because we have emotions does not mean we’re bad people or bad doctors or bad nurses or bad any other type of healthcare provider. I think that there’s a lot of stress about admitting out loud that something is hard or that we feel a certain way because we’re taught in our professions to really remove our feelings from what we’re doing and to maybe not even feel angry at all about what someone says or that it’s somehow taboo to feel angry at something a patient does, or, you know, something we’re exposed to at work.

But I think we really need to have outlets with each other where we’re expressing our emotions in a healthy way, and then, you know, going to work every day because we still do. And that’s still part of our job, but I think it’s possible to have emotions and have reactions and have them be validated by other people, and at the same time, still do our jobs.

Marshall: But many people think public health measures, like vaccines, should it be a personal choice? And yet, they’re being mandated. So, are decision makers enabling, in some ways, this compassion fatigue by mandating them?

Gold: When you say decision makers, do you mean people in hospitals by telling healthcare workers to get it?

Marshall: Oh, no, it’s a government mandate for employers with more than 100 employees to have the vaccine. So then it creates a pushback by people being concerned about the government telling them what to do with their body. And so the vaccine, in that sense, has created a dynamic that perhaps has upped resistance to it since the COVID pandemic has been politicized really from the beginning.

Gold: I don’t know if I know the answer to that question. I think that it’s been so hard in so many ways from the beginning. I think that there’s no clear turning point. At what point did we become — going from heroes to people that had to hide their scrubs and their ID cards outside the hospital? But at some point that happened and it’s just really gotten worse for people.

And whenever that happens, a lot of these things just make it harder. I do think that there are things that are public policy decisions that should be public policy decisions. I can’t make comments on that because I do not work in public health and I do not evaluate all of the decisions, but I do think that all those things, like we don’t do healthcare in a bubble. We do healthcare in the world. And so we’re always interacting with the world within it, and it makes it much harder because people have opinions, especially in this country, about all sorts of things and maybe things that we don’t view as political have become politicized.

Marshall: It’s interesting, when you used that phrase that they went from being heroes to hiding their scrubs, it reminded me of a movie quote, where if you don’t die a hero, you live long enough to see yourself become a villain. Is that what you’re hearing from these caregivers?

Gold: I mean, that’s sad to think of that, them feeling like villains. I don’t know that they necessarily identify with either, because I think they didn’t like the word hero either, for some reasons, because it’s a hard moniker and it carries with it some lack of humanity.

But being a villain, I mean, they are written into the story in ways that they don’t feel like make sense. Like they’re not lying about who’s dying of COVID and who’s not, or they’re not trying to suggest something to hurt people or they’re not hiding beds or they’re not trying to prevent people from access to medications that work. I think things like that really do make people out to be the bad guy when really they’re just the scientists.

And so the narrative really does get spun in a way that is not on science’s side, which as, you know, symbols of science make it hard for healthcare workers.

Marshall: You mentioned earlier how a lot were saying that they don’t know if they can continue doing this job because of the compassion fatigue. Is that an impact we’re going to see on the healthcare system? We’ve already seen mass retirements in certain sectors after the pandemic [began]. Is that something that is coming now in the health sphere?

Gold: I think so. I mean, I don’t have a crystal ball, but I think that if you look at the emotional impact of this, if you think about the fact that healthcare workers had bad mental health before COVID, then have compounding mental health problems over COVID, then we’ll finally get a chance to breathe after COVID and look at what happened and might say, like, did I feel valued by the place that I work? Do I feel valued in this profession?

And if they answer the question no? I mean, yeah, they are going to leave. I think a lot of people don’t leave in an acute bleed, right? Like they’re trained to fix the bleed first, so they’re trying to stop the bleed before they leave, but sometimes they have to leave for themselves and there’s only so much they can handle.

Sometimes they’ll figure out that it’s really affected them when they get a chance to actually assess the damage. Sort of like post eye of the hurricane or something like that. But I don’t know that we’re quite there yet, but it wouldn’t surprise me if people were to really sit with it and realize that the career wasn’t what they thought it would be, or they didn’t feel as valued or … they just couldn’t do it anymore. At least they need a break from it.

Marshall: It’s interesting. You said valued at the place they work or within the profession. Is that ultimately coming down to being valued by society? And society not taking on these preventative measures — causing that compassion fatigue, turning their dream job into perhaps this question?

Gold: Society is definitely part of it. It’s like the big bubble where all of it lies, right? But I don’t think healthcare is blameless. I mean, healthcare is its own culture. Healthcare has its own problems that existed long before … healthcare in different institutions probably sided with employees more than others or supported employees more than others.

And I think people who work in institutions where they feel more supported, like mine, where they gave people money for having worked over the pandemic, I think feel more supported. That feeling is respect. And that is not maybe something that everybody feels everywhere and I’ve heard that. And I think it is partially society, but healthcare is its own culture anyway, and it definitely compounds it too.

Marshall: So, what is the role of basic mental healthcare here?

Gold: Um, in …

Marshall: Loaded question?

Gold: In terms of actually compounding compassion fatigue, or in terms of all of our kind of states right now?

Marshall: Well, let’s just keep it focused on compassion fatigue. We could have a whole other episode on our general mental state.

Gold: I mean, healthcare workers in general have … studies would say you go into med school with equivalent mental health of your age-matched peers. Med school makes you have depression rates in the high 20s — 20% to 28%. It gets worse over training, with intern year being the highest risk really for you.

Then we have among the highest suicide rates of any profession. You add in risk factors like all of COVID, and you see some of the data that we’re slowly seeing emerge, which is a lot higher rates of depression for people who worked in the front lines in New York, with a lot of people expressing that they had acute stress disorder, which is a measure of PTSD, just like really close to the trauma.

A lot of people are not sleeping. And what you see is that if people aren’t sleeping or people feel sad, it makes it a lot harder to deal with empathy. It’s really hard to be empathetic when you can’t even care for yourself. If nobody’s caring for you, your institution doesn’t care for you, and you also don’t care for you, it’s not leaving a lot of space.

I think there’s a lot [for the] role for basic mental healthcare. It’s what I try to do. I mean, I’m a psychiatrist for healthcare workers, their spouses, and their college-age kids. And half of what I do is run around trying to tell them that they’re allowed to ask for help and that it’s normal for them to feel the way that they’re feeling. We exist and they are allowed to find us. And that’s a much harder thing than you’d expect because stigma is really high in our field.

But some people are slowly getting there. I think we’re talking about it more openly. But there’s a lot of role of just actually prioritizing ourselves in the equation in all ways, including valuing mental health equivalent to physical health.

Marshall: And so for those dealing with compassion fatigue, what tips would you have for them going forward? Especially — kind of coming back full circle here, Dr. Gold — as more vaccines roll out. The age group goes down to 5 and up, and possibly we don’t see the vaccination numbers trickle up as high as health professionals would like.

Gold: I’m sure that they won’t trickle up as high as health professionals would like, unfortunately, because we have high hopes. But when I think about what we can do, a lot of what I talk about is really basic. And sometimes people say, “that seems so simple,” but if it was simple, we would all be doing it.

So, you know, one of the things is obviously naming emotions and giving space for emotions and actually asking yourself how you’re doing. We don’t ever give space for ourselves because we’re doing so much for others. Like in work, at home, in our friends and family, you need to be able to say, how am I? And answer that question, and it’s OK if the answer is angry or sad or anxious. Leave space for that. And then just let it be.

And then from there, try to figure out what kind of coping skills you like and work for you. I think we try too hard to fit a circle into a square and do whatever coping skills the hospital provides, or someone told us was trendy on Instagram.

And it’s much more helpful to think of coping skills more like hobbies, and say, I actually like running. I actually like watching this stupid TV show. That’s actually comforting to me. This is what I want to be doing in the me time that I have, and that’s what I’m going to do to feel better. And actually turn to those things instead of just forcing, like, mindfulness, because the evidence says it works, but if it works for you, great. But if you don’t like it, don’t force it. I think that’s really important.

I think boundaries are another thing that’s incredibly important. I think that comes up in a lot of different ways for healthcare workers. So, you know, social media boundaries are one thing because we talk a lot about the hardships of people over social media. And if you’re dealing with that and work, and then you’re reading it on the news, and then you’re reading it on social media, there’s only so much of that you can take. So figure out how your emotions are feeling when you’re scrolling. And when you’re talking to people on social, or watching the news, give yourself a break. Don’t watch it before bed. Do something that’s more fun.

Take your phone out of your room, and make it not the first thing you look at in the morning and the last thing you look at before you go to bed. Give yourself a little bit of space from it. Know that the whole world isn’t COVID. Tell your friends and family that it’s nice to talk to them, but you’d rather not talk about vaccines and COVID, if you want to.

It’s OK to say that. I think we worry about saying things like that because we’re hurting our friends’ and families’ feelings. But they are asking because they’re interested or they’re asking because they don’t have access to the same kind of day-to-day view and information that we have. But if you can’t talk about it, because what you see is too hard, you don’t have to talk about it. You can say, I don’t want to talk about it. Can we watch TV together instead? Can we go for a walk in the park and talk about something completely different? Can we just sit here and be together and do something different? Can we play a game? Anything else where you can still feel like you’re being social, seeing your friends and family, not isolating yourself, but not having to talk about COVID all the time. I think it is really important for us.

Marshall: And, Doctor, would those be the same tips for somebody who maybe isn’t a caregiver or a health professional, but is just fed up with COVID being prolonged?

Gold: Yeah. I mean, a lot of the same tips. I think you maybe don’t have as much exposure day-to-day to COVID in your workplace. I would think. It sort of depends on what you’re doing, but you definitely do in the news and you definitely do on social media. So taking stock in that.

Feelings are something as a society we’re not comfortable with. Healthcare workers are really not comfortable with them, but there are other fields that feel the same. So definitely is something to get used to.

Other fields’ boundaries can look a little different because you might be working from home and you might be working well into the evening and doing emails really late at night. So separating work and home is really important in those instances. Taking off alerts and also really being aware that vacation days are not just to get out of town, but to give your mind a break and give your mental state a break. And so just because you can’t necessarily go somewhere when you want to doesn’t mean you should not be taking vacation days ever, which is something that a lot of people were doing over COVID. So that’s really important.

And then for the whole group — get mental health help if you need it. I think I absolutely see people on this whole spectrum of things. I said at the beginning, like they all have different definitions and some various little different symptoms, but, you know, we spend a lot of time putting things in buckets. But really when it comes down to things, if you feel bad, if it’s interfering with your life, if you’re not getting what you want to get done, if you feel like it’s worsening, if you feel like it’s affecting you, your family, or patient care, get help. Ask for help. It’s not something to be ashamed of. It’s not a weakness, and people like me are there to help.

Marshall: That’s such an important tip, and I think it’s a good lesson in reconnecting with your empathy for everyone who might be frustrated with those who push back on preventative health measures.

Gold: I mean, I think everybody has feelings. That’s where I always go back to. There’s a feeling behind everything. I even feel that way about, you know, people who are trolls or people who have different opinions than me.

There’s usually a feeling behind everything that you can try to relate to. And that’s how, you know, psychiatrists kind of balance having their opinions be different maybe in life than some of the people they see. Because we don’t talk about our opinions, right? So I think everybody’s feelings are valid in all instances, even if maybe their opinions feel very different from yours.