Strong Back, Soft Front

How do we remain open to suffering without being overwhelmed by it?

In this episode of The Only Life You Could Save, Dr. Cassie Ferguson explores one of the most important—and least taught—skills in medicine: how to care deeply without losing yourself in the process. Building on the previous conversation about vulnerability, she examines the difference between empathy and compassion and explains why one can leave us depleted while the other can sustain us.

Drawing on neuroscience research, contemplative traditions, and her own experiences caring for patients and teaching medical students, Dr. Ferguson introduces practical approaches for cultivating compassion, emotional resilience, and healthy emotional hygiene. Along the way, she challenges aspects of medical culture that encourage detachment and stoicism while offering a different vision of what it means to be present for suffering.

This episode is an invitation to develop what Buddhist teacher Roshi Joan Halifax calls a “strong back and soft front”—the ability to remain grounded and resilient while keeping your heart open to patients, colleagues, loved ones, and yourself.

In this episode:

• Why many healthcare professionals become emotionally numb
• The hidden emotional curriculum of medical training
• The neuroscience of empathy and compassion
• Matthieu Ricard and the "compassion versus empathic distress" research
• Loving-kindness meditation and compassion training
• Self-compassion as a foundation for resilience
• The practice of "One for me, one for you"
• What it means to have a strong back and a soft front
• How physicians can stay connected to suffering without being consumed by it

Key Takeaway:
Empathy allows us to feel another person's pain. Compassion allows us to respond to that pain with courage, love, and purpose. The difference matters—not only for our patients, but for our own well-being and ability to sustain a meaningful life in medicine.

Transcript

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During our last session on vulnerability and perfectionism, we began to look at what it requires of us to witness the suffering of our patients and their families. Without a strategy, it's easy to get caught up in anger or despair or hopelessness. We risk becoming numb to not only the tragedies right in front of us, but all tragedy anywhere. And perhaps even worse, and I believe one of the reasons why I have struggled with depression, we risk becoming numb to joy. I want to lean in here and begin to think about the how. How do we sit with the truth of what we witness every day and remain whole? What skills do we need to practice to be present for suffering without being swallowed up by it? Unfortunately, many aspects of the clinical learning environment in which you are learning or will learn to care for patients reinforce bad emotional hygiene. Emotional hygiene being the noticing and tending to your psychological health. You're typically shuttled between different clinical environments every month or even every week, each one with a new set of busy supervising residents and attendings. This may leave you feeling unsure, unsafe, or alone, and left to sort through what you're seeing and feeling by yourself or with your equally as inexperienced peers. In contrast to the preclinical classroom, where everyone is subject to the same set of circumstances, you are an NM1 on clinical rotations. Everyone's struggling to digest and process what they see every day in the hospital, clinic, or operating room to which they've been assigned. A sense of isolation and even loneliness during clinical rotations comes up frequently in my conversations with medical students. Potentially more harmful than wrangling with our own emotions by ourselves is learning to wrangle with them from observing poor role models. It's well advertised that physicians are burned out and that the COVID-19 pandemic only exacerbated this problem. At the end of 2021, a national survey found that nearly 63% of U.S. physicians reported symptoms of burnout. This was up from 38% in 2020. Attending physicians carry tremendous responsibility and administrative burden and are often stretched too thin to be fully present for students. Residents, the group of physicians who are charged with most of the teaching in the hospital, are overworked and underappreciated. Running the daily operations of the hospital, clinic, and operating room leaves them with little time to talk with medical students about their emotions and little reserve to demonstrate healthy coping mechanisms. It's also important to note that the vast majority of us currently practicing medicine were not taught any of these skills. We were taught, said a colleague who had been reprimanded by our hospital's professionalism committee for berating a younger colleague, that only the patient's emotions should matter. As an inexperienced and awkward medical student in the clinical space, it was difficult for me to know which examples to adopt and which to abandon, a decision that was clouded by my intense need to fit in. I often felt I had no choice but to mimic my burned-out supervising attendings or residents' blasé attitudes towards events that I found incredibly distressing. One Friday evening during my trauma surgery rotation, our team cared for a man we guessed was in his 20s, who had shot and killed his girlfriend and then turned the gun on himself. He died within minutes of arriving in our trauma bay, despite heroic interventions. Immediately, my supervising resident handed me the central line kit, pointed at the barely dead patient's neck, and casually said, Well, you may as well practice putting in a subclavian line. As medical students, you stand with one foot still in the real world, where a tragedy like this would at least be acknowledged as such, and where my resident's response felt inhumane or even cruel. Your other foot, however, is planted in an alternative reality where it's just another Friday night on the trauma service. On any given day during my clinical rotations, I would feel pulled toward one world or the other, confused about what this choice would mean for my end-of-the-month evaluation and my willingness to look at myself in the mirror at the end of the day. Looking back on these experiences in medical school now, I have tremendous empathy for my former supervisors. As I moved through medical training and witnessed more patient suffering, presided over more deaths, and sat in the presence of more pain, I began to understand how much these physicians were suffering too. I also began to see more clearly the ways in which the culture of medicine valorizes stoicism, sarcasm, and self-deprivation over acknowledging our own suffering out loud. This way of doing things is no longer serving us. We need a new guidebook for navigating the truth of our everyday experiences, the feelings and behaviors that come up in the course of learning to care for suffering people, one that honors our emotions as natural responses that flow from our humanity, from the part of ourselves that called us to medicine in the first place. If I was writing this guidebook, the first lesson would be one I learned from Mateau Ricard, a French molecular geneticist turned Buddhist monk, who has been dubbed the happiest man alive, and who talks about the difference between empathy and compassion. Learning about this difference has given me tremendous insight into how we can more deftly be present for suffering. In 2015, Ricard published a book called Altruism: The Power of Compassion to Change Yourself in the World. In it, he writes about collaborating with neuroscientist Dr. Tanya Singer to map the regions of the human brain involved in the experience of empathy.

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Dr.

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Singer had become interested in learning about the neuroscience of empathy ever since hearing about the work of Italian researcher Giacomo Rizzolotti. In 1990, Risolotti is sitting across from a monkey in his lab at the University of Parma, trying to determine what pre-motor cortex neurons fire in the performing of an action. By hooking an electrode up to a neuron and a loudspeaker and listening for activity, Risolotti and colleagues could determine whether that specific neuron fired when the monkey picked up a raisin that was set in front of him. What they weren't expecting was that that same neuron fired when the monkey watched one of the scientists pick up the raisin. In other words, these neurons responded equally when the monkey performed the action and when they witnessed someone else perform the same action. Rizzolati and his team named these cells mirror neurons. Dr. Singer and her team were interested in exploring the connection between these mirror neurons and empathy. So they began to use an imaging technique called real-time functional magnetic resonance imaging, or RTF MRI, to study which areas of Ricard's brain were involved in the experience of empathy. They did this by observing the changes in blood flow in his brain, indicating which areas of the brain were using the most oxygen. As someone who had trained his attention and awareness through tens of thousands of hours of meditation, Ricard could adeptly and reliably enter into and out of mind states like empathy better than a non-meditator, making him an exceptional subject for study. In one of their experiments, Singer asked Ricard to focus his mind on the suffering of another living being and to allow himself to feel their suffering as if it were his own. To do this, Ricard imagined someone close to him being injured in a car accident or focused on the images he'd seen on television of physically and mentally handicapped children living in squalor in a Romanian hospital. While Ricard did this, the anterior insula and the cingulate cortex of his brain lit up, areas that are activated when people experience pain firsthand. In other words, the same areas of the brains that are activated when we stub our toe light up when we witness the pain of another. As he lay there, Ricard said that entering into resonance with this pain soon became intolerable. He felt powerless and depleted and struggled to continue. After a series of meditations like this, Singer asked Ricard to pause so that the team could set up the next experiment. Relieved, Ricard immediately began silently offering up phrases of safety, health, happiness, and ease to those with whom he had been empathizing. While he did this, he said, the images of the children suffering were still just as present and strong. But instead of creating in me a feeling of distress and powerlessness that was hard to bear, I now felt a profound, heartwarming courage linked to limitless love for these children. While this wasn't a planned part of the study, as Ricard continued to silently offer up these phrases, Singer noted a new and distinct pattern of cerebral blood flow on the MRI. While the pain centers of his brain remained active, so too were the medial orbital frontal cortex, the anterior cingulate cortex, and ventral striatum, a cerebral network traditionally associated with positive emotions like love and affiliation. Singer asked Ricard what he was doing, and he explained to her that he was meditating on unconditional compassion, trying to feel a powerful feeling of love and kindness for people who were suffering. He remembers feeling as if he could have stayed in that state forever. This was an important, albeit accidental, discovery, and one that has been game-changing for me as someone who is frequently called to witness the suffering of others. This finding means that when we focus our empathy on another's suffering, we are at risk of experiencing empathic distress. Like Ricard, we can get caught up in the emotions we imagine we would have if we were experiencing the same thing. But if we instead bring compassion into that space, if we focus our concern and motivation to help on the suffering person in front of us, our brains react with positive, other-oriented feelings. Fortunately, researchers have demonstrated that we may train ourselves to respond to others' suffering with compassion and to avoid empathic distress. In contrast to a group of participants who attended a two-day memory training, participants who attended a two-day empathy training had an increase in negative affect and brain activations in the anterior insula and anterior mid-singulate cortex in response to seeing videos of people suffering. However, a subsequent two-day compassion training reversed these effects. It decreased negative affect back to baseline, increased positive affect, and increased brain activations in the medial orbital frontal cortex, the anterior cingulate cortex, and ventral striatum in response to similarly distressing videos. The central practice and the compassion training that these study participants experienced has become one of the core practices that I teach and one that I've adopted myself. Referred to as loving-kindness practice or loving-kindness meditation, it's a way to cultivate compassion that has roots in the ancient traditions of Hinduism, Jainism, and Buddhism. Loving-kindness meditation involves mentally sending goodwill, kindness, and warmth towards others by silently repeating a series of mantras. For example, you might bring to mind an image of someone who is suffering and repeat these phrases. May you be happy. May you be healthy. May you be safe. May you live life with ease. One of the reasons I adopted loving-kindness meditation and teach about it in medical school was the research that demonstrates how readily the benefits manifest and how long they endure, even after a relatively short period of practice. This is an uncommon finding for practices related to well-being. As meditation research giants, Richie Davidson and Daniel Goldman explain in their book, Altered Traits, most types of meditations are effective at altering our state of mind, but few induce new and lasting traits without monk-level engagement. Loving-kindness meditation has been shown to not only change how we experience the suffering of others, as demonstrated in Singer's lab, it also makes it more likely that we'll help someone in need, even when there's a cost to us. We can see benefits from practicing loving-kindness meditation in as little as eight hours of practice. These findings may relate to a human biological preparedness related to learning compassion. As Davidson and Goleman hypothesize quite beautifully, our brains seem primed to learn to love. Loving-kindness meditation and courses, including loving-kindness meditation and related practices, can also strengthen self-compassion. Self-compassion, or the desire to relieve one's own suffering with mercy, is a way of relating to ourselves that's been shown to have numerous benefits for our well-being, including reduced levels of stress, anxiety, and depression, as well as increased emotional resilience. Kristen Neff, a pioneer in self-compassion research, describes the three components of self-compassion as speaking to ourselves kindly, understanding negative experiences as part of the human experience, and being mindful of painful or critical thoughts and feelings without over-identifying with them. We'll talk more about self-compassion in future sessions, including the research we've done at the Medical College of Wisconsin, demonstrating a strong positive relationship between self-compassion and well-being in medical students. But before all that, I want to give you a sense of what it feels like to operationalize it so that it doesn't just sit there. In the Mindful Self-Compassion workbook, Neff and her colleague Christopher Germer share ideas and practices aimed at increasing self-compassion that are based on scientific research and on their experience teaching participants in the Mindful Self-Compassion training program they developed together. One of the practices in the workbook and one of the core practices taught in the MSC training program is called giving and receiving compassion. Although I've changed the name to one for me, one for you, which is what I call it when I teach the practice to students. To begin, sit comfortably, close your eyes, and if you like, put a hand over your heart or another soothing place as a reminder to bring not just awareness, but loving awareness to your experience and to yourself. Take a few deep, relaxing breaths, noticing how your breath nourishes your body as you inhale and soothes your body as you exhale. Continue feeling the sensation of breathing in and breathing out. Letting yourself savor the sensation of breathing in, noticing how your in breath nourishes your body. Breath after breath. As you breathe, begin to breathe in kindness and compassion for yourself. Just feel the quality of kindness and compassion as you breathe in. Or if you prefer letting a word or image ride on your in breath. Visualize that person clearly in your mind. Offering the ease of breathing out. If you wish, send kindness and compassion to this person with each outbreath, one breath after another. Begin breathing in for yourself and out for the other person. In for me and out for you. One for me and one for you. And as you breathe, draw kindness and compassion in for yourself, and breathe kindness and compassion out for the other person. Allowing this meditation to be as easy as breathing. Allow your breath to flow in and out, make the gentle movement of the ocean, a limitless, boundless flow, flowing in and flowing out. Let yourself be a part of this limitless, boundless flow, an ocean of compassion. When I'm sitting with a child in pain, or across from a parent angry with me about the long wait, when I'm listening to a patient tell me what it felt like to break their arm, or a resident relay the details of a patient's sexual assault. I listen while breathing in compassion for myself and breathing out compassion for them to maintain a connection with whomever is in front of me while not becoming overwhelmed with my own emotions that naturally arise in these situations. Attending to ourselves while being present for the suffering of others makes it possible to stay proximate to what's true, to be present for even the most incomprehensible suffering. It has shown me that there is healing in our response. When I'm present for patients in this way, I have the strength to sit with suffering and the fierce motivation to transform it. At the same time, I can let myself be moved by their pain without rushing to find a way to protect or numb myself from it. Roshi Joan Halifax is a Buddhist teacher, social activist, and author. She speaks of attending to others in this way as having a strong back and a soft front. In her 2014 TED Talk called Compassion and the True Meaning of Empathy, Halifax says of compassion, it takes tremendous strength of the back to uphold yourself in the midst of conditions. But it also takes a soft front, the capacity to really be open to the world as it is, to have an undefended heart. Truly opening to the world as it is, dropping our guard and listening to our patient's truth also opens us up to the power in their stories. While some of these truths naturally reveal sadness or grief and even hopelessness or guilt or anguish, we should not neglect to recognize or weigh the transformative impact of someone sharing their story with us. Opening to our patient's stories can spark a sense of shared humanity and deepen our compassion even more. A strong back is a reminder to stay present with our patient's suffering or our own difficult emotions, even when we have a strong urge to pull away. It's also, I believe, a reminder to me of our agency as helpers. One of the gifts of the profession of medicine is learning a set of skills that makes you useful to suffering people in a way that less than 1% of the world can be. As physicians and physicians in training, we're not charged with uncovering the suffering of our patients simply to bear witness. We're charged with understanding it so that we can help our patients heal. Whether that means choosing the correct test, making a diagnosis, compassionately delivering difficult news or offering a useful procedure or medication. This unique and powerful skill set can transform our sense of helplessness in the face of suffering into helpful action. Even in medical school, there are many ways in which you can be helpful to patients, asking open-ended questions, listening attentively, spending time with admitted patients after rounds, holding a patient's hand during a painful procedure, and advocating on behalf of your patients. These seemingly small but significant actions connect us to our sense of purpose, a sense which is central to healthy psychological functioning, including resilience and recovery from traumatic events. I am very aware that as a group of people who witness both the desperation and incredible resilience of patients who face tremendous suffering, that it can feel awkward to hold ourselves in the same compassionate space that we hold our patients. Many of us wrestle with the flawed belief that our feelings only distract from the patient's suffering or compromise their care. Medical students are especially prone to discounting their own emotional responses to trauma, feeling like mere onlookers in the very periphery of the concentric circles of care surrounding a patient. In the moments after the death of a child in the emergency department, I still often feel that my own experience of sadness somehow takes away from that of the parents or the family, almost as if there's only so much to go around. While comparing our suffering to that of our patients comes from a loving and kind place and can provide important perspective, it often leaves us overwhelmed with guilt or shame, both self-oriented emotions. But hurt is hurt. Acknowledging our own emotions with compassion leaves us with the capacity to tend compassionately to the patient in front of us. As we come to a close, I invite you to consider this. The capacity to bear witness to suffering without losing yourself is not a fixed trait. It's a skill that can be cultivated with practice, intention, and care. You came to medicine not to become numb to things around you, but to be deeply alive to it, to bring your presence, your knowledge, and your humanity into the spaces where they're most needed. By strengthening our back and softening our front, by turning toward both our patient's pain and our own with compassion, we create the possibility not just of surviving this work, but of being transformed by it. Let us commit to building a culture that honors this kind of strength, the kind that keeps us open, connected, and whole. And as always, keep reaching out. I'm grateful that he reached out to ask whether I might record these lectures, and grateful for his talents that made it possible to do so. Thank you also to Dr. Ashley Pavlik, a friend and colleague, and the course director of the Good Doctor at MCW, who makes space for this content in our curriculum. To Dr. Dave Marcolis, the chair of the Department of Pediatrics at MCW, who pays for my time to teach medical students about well-being. To my pediatric emergency medicine colleagues who take exceptional care of kids and of one another. To my family who reminds me that medicine comes second. And to my students, past, present, and future, for keeping me honest always. Finally, thank you to Alex Brown for creating our theme song, Cam Collins for his sound production skills, and to Madeline Sturm for her brilliant art and design working on the microphone.