What if burnout isn’t caused by caring too much? In this episode of Healing People, Not Patients, Dr. Jonathan Weinkle speaks with Dr. Brian C. Miller about why compassion is not the enemy of sustainable healthcare work. Together, they explore empathy, humility, emotional boundaries, and the hidden narratives that shape how clinicians survive or thrive, in helping professions.
Is burnout really caused by caring too much?
In part one of this two-part episode of Healing People, Not Patients, Dr. Jonathan Weinkle welcomes Dr. Brian C. Miller for a powerful conversation that challenges conventional wisdom around burnout, compassion fatigue, and emotional exhaustion in healthcare. Drawing from his book Reducing Secondary Traumatic Stress: Skills for Sustaining a Career in the Helping Professions, Brian argues that compassion itself is not draining, rather, genuine compassion can become a source of energy and resilience.
Together, they explore the difference between empathy and emotional over-identification, the role of humility in patient care, and why emotional boundaries are essential for sustaining meaningful work. Brian shares insights from his experiences as a therapist and from the devastating loss of his son to leukemia, reflecting on how healthcare professionals can remain emotionally open without becoming overwhelmed. Through stories, psychology, and spiritual narrative, the episode reframes burnout not as a failure of resilience, but as a challenge of meaning, boundaries, and connection.
Top 3 Takeaways:
About the Guest:
Dr. Brian C. Miller is a therapist, researcher, and author specializing in secondary traumatic stress, emotional resilience, and sustainability in the helping professions. He holds a PhD in social science research from Case Western Reserve University and has worked extensively in behavioral health with both adults and children.
Brian is the author of Reducing Secondary Traumatic Stress: Skills for Sustaining a Career in the Helping Professions, where he challenges conventional burnout narratives and offers practical approaches for cultivating empathy, emotional boundaries, and resilience in caregiving professions.
🔗 Connect with Dr. Brian C. Miller:
Website: https://www.cecertmodel.com
📚 Book: Reducing Secondary Traumatic Stress: Skills for Sustaining a Career in the Helping Professions
Healing People, Not Patients explores ways to enhance medical practice by infusing it with compassion, humanity, and a deeper sense of purpose, aiming to help healthcare professionals rediscover the "soul" of their work. Framed around the four questions of the Passover Seder, it probes how to transform medicine for the better, promoting an empathetic and supportive approach that empowers patients to create meaningful, sober lives, while drawing on Jewish teachings about community and friendship.
"Our theme song, "Room for the Soul," is available on Bandcamp at https://jonathanweinkle.bandcamp.com/track/room-for-the-soul."
Dr. Jonathan Weinkle is an internist and pediatrician who practices primary care at a community health center in Pittsburgh. He strives to be a "nice Jewish doctor" focused on patient-centered healthcare, emphasizing effective communication and holistic well-being.
He teaches the courses, “Death and the Healthcare Professions” and “Healing and Humanity” at the University of Pittsburgh, authored the books Healing People, Not Patients and Illness to Exodus, and runs ‘Healers Who Listen’, where he blogs on healing and Jewish tradition. Once an aspiring rabbi, he now integrates faith and medicine to support other physicians and his own patients.
🌐 Website: healerswholisten.com
🔗 LinkedIn: linkedin.com/in/jonathan-weinkle-3440032a
📸 Instagram: @HealersWhoListen
📘 Facebook: @JonathanWeinkle
[00:00:00] Burnout. We think of burnout as the young Hollywood star or up-and-coming wunderkind athlete or scary, smart professional whose career resembles a literal shooting star. They flash brightly across the sky, burn up all their creative, intellectual or emotional fuel, then crash, smoldering to earth, never to rise again.
Among medical professionals, burnout leads to suicide, to people quitting the field, or to those who remain becoming crass, uncaring professionals who should leave the field. The most famous case of burnout in the Torah is that of Nadab and Abihu, the two sons of Aaron, the high priest. Just days after the dedication of the Mishkan, the mobile sanctuary in the desert, they approached the altar with a sacrifice of their own, a strange fire.
It's not clear what was wrong with their offering, but it is clear that they end up dead as a result. According to Midrash, the filling-in-the-blanks folklore of Judaism, they are literally burned out from a fire of God entering their bodies [00:01:00] through their nostrils. Apparently, they got too close, encountered forces they couldn't handle and, for all their youthful devotion, ended up as charred as the animals that they had been bringing to the altar.
When I taught this story at Congregation Romemu in New York a few years ago, I likened Nadab and Abihu to medical interns left to run the hospital overnight with no backup, set up for failure. In the class that day was a young woman doing her pediatric internship at a hospital in another part of New York.
She had taken an hour subway ride on her day off to be in this class that she felt was speaking directly to her experience. She shared with us how her days oscillated between parents enraged by the way that the system treats them, to her own rage at parents seeming to neglect their children's basic needs, to frustration and despair about the lack of resources she had to treat those with whom she could make an alliance, and that was a year before the COVID pandemic.
The unofficial usual message to such trainees is, "Grow a thicker [00:02:00] skin. Don't invest too much emotionally and protect yourself, or you'll burn out." My guest today is Dr. Brian C. Miller. He's a therapist, a researcher, and the author of the book, "Reducing Secondary Traumatic Stress: Skills for Sustaining a Career in the Helping Professions."
I won't spoil the whole message. We're about to hear Brian tell us we've got burnout and its remedies all wrong. Stay tuned. Welcome back, everyone, and this is a true welcome back. I've been on a little bit of a hiatus for the month of April, so this is my first episode since the end of March, and I'm really pleased to be joined by a new friend that I've just met now, Dr.
Brian Miller. And I'm gonna introduce Brian in the way that I told him I would, which is to tell you how I found out about him. Brian is the author of the book, "Reducing Secondary Traumatic Stress: Skills for Sustaining a Career in the Helping Professions," this book right here. And I don't often credit [00:03:00] algorithms, at least online algorithms, for much of anything.
But I do have to give Amazon's online algorithm for figuring out that this was a book that I needed. I bought it just before the end of 2022, at which point I was pretty fried from two years of trying to be both a community leader and a healthcare leader during the pandemic at its various stages, whether that was the initial lockdown or all of the decisions around how to carefully reopen, how to promote vaccination and personal protection, community protection.
And also being the no-fun police for my synagogue, my kids' school, for a whole bunch of different organizations that I was connected with. And between that and the political landscape in the country, it became really, really difficult. And when Amazon told me I should read this book, I don't usually listen to the algorithm, but I listened.
And what I found was a [00:04:00] fascinating discussion of themes like burnout, compassion fatigue, and a whole bunch of other themes from a perspective that was unlike anything I had previously read or heard. There's sort of a party line about burnout, and Brian Miller is holding his own party. He is inviting different guests and serving different beverages and food, and I think that his house is the one I wanna be at.
So who is Brian? He has worked as an adult behavioral health therapist, as a child therapist. He has a degree in social science research PhD from Case Western Reserve University, and has lived in a few different parts of the US. He is coming to us tonight from the mountains near Salt Lake City, and I am super pleased to have you here.
Thank you so much for agreeing to do this, Brian. Oh, thank you, Jonathan. It's truly been a conversation that I've been eager to have. Wonderful. So as I mentioned in the introduction, Brian, this is a very different book on compassion, on [00:05:00] burnout, on secondary traumatic stress than anything else I've ever read.
I've been in primary care medicine for 18 years. I've been a leader in my organization for the last two years, and I have attended a lot of burnout prevention workshops going, dating back to residency really, which was early. There's been a lot of attention on burnout in the last five or 10 years in particular, and one of the things that strikes me about it is most of the burnout prevention approaches that I've encountered are very self-centered.
They focus on self-care, unplugging, things like that. And you're leaning into a very humble approach to things that is not at all self-centered. In fact, one of the stories in your book is a story that you're holding up as an example where the patient you saw for the very first time at the end turns to you and says, "Eh, you're nothing special."
So tell us about how the humility that you bring to your story works to your advantage- And to, to anybody's advantage who's trying to avoid burning out [00:06:00] Y- and you got the delivery precisely correct. You're nothing special. And I think the answer is i- if you think of humility on one end, think of its opposite, which is about ego.
And even when you say, and I will remember your introduction of me and having a party by myself, that when we talk about, for instance, compassion fatigue, that compassion fatigue isn't and never was real. It is physiologically impossible for it to be real because compassion is not fatiguing. Compassion is an energy source.
And I even note that when you talk a- about empathy as a moral imperative, whereas Brian Miller's version of empathy is it's an energy source. And so the connection I'm making to humility is that when we stop [00:07:00] giving up ego, in fact, the rest of the story with the very patient you were describing that said, "You're nothing special," is that, uh, at the time when I was young and pretty, at that time, I was trying to defend my ego as, "Yes, I am something special."
Mm-hmm. And so I immediately had this rise of defensiveness, which took me away from empathy for this woman. And that without the ego piece of that, if I see as primary my, my imperative to cultivate compassion or empathy, whichever term we're gonna select here, that what I n- need to do is set aside the fact that I felt personally insulted by that.
I'm not anything special. Why is it even insulting when she says, "You're nothing special"? And that as soon as I set that aside and say, "What is she saying to me?" It [00:08:00] becomes crystal clear what she's saying to me, which is, "I'm worried you are not gonna be able to help me get well." And that just requires that simple act of setting the ego over here to listen more fully.
You could put it, knowing that I'm speaking to a physician, into the most fundamental healthcare question there is, which is, where does it hurt? And that I've gotta set my ego aside in order to just ask myself the question, where is she hurting? That's a great way to phrase it. I love that. As you were talking, that way that you described your visceral reaction to her saying, "You're nothing special," it reminded me of a very old article, which I don't know if you've encountered in your therapy work.
It's something that floats around a lot in the medical literature- Uh, and a lot of my éminence grise attendings, the folks that were the [00:09:00] senior attendings when I was training 20, 25 years ago, would talk about this article, The Care of the Hateful Patient. And it's a terrible name for an article. Mm-hmm.
Nobody would ever get an article published under that name now. And if you actually read the article, James Groves, who was the psychiatrist that wrote it, wasn't talking about the fact that these were patients that you should hate. It was that these were patients who aroused hateful emotions in the clinician.
Correct. Correct. That they made you feel things that you were ashamed of feeling, but you felt them anyway. And often they were things that would provoke you to do things in defense of your own ego that were not helping the patient or you. For example, the patient, he uses labels like help denying or clinging or whatever, and often the relationship would begin with the patient saying, "Oh, thank God.
You know, nobody else listens to me. You're the only one that listens to me." And it's a particular trap for people like me who kind of pride ourselves- Right, right. I know that ... on listening and being compassionate where a lot of people have [00:10:00] been really treated badly. But every once in a while there's an extreme version of that really feeds your ego, and so you wanna prove that they're right, that they're, you really are gonna help them where nobody else could do it.
And once you realize that maybe those other people couldn't do it because they're really hard to help, you actually end up doing a better job because when you don't set boundaries, you overextend yourself into territory where you don't actually know what you're doing. Right. Oh, a- and again, once the ego can be set aside, and it does work in both directions, that projective identification, as we call it, where they set you up as this great thing because they wanna borrow that kind of power from you.
But that's the emotional labor aspect of helping work, is the fact that whichever side we're coming from, but when they themselves are acting hateful, and yet we as this caring professional with [00:11:00] unconditional positive regard are acting as if we still care about them when really we're raging, we're offended, and we're upset, and that really characterizes the emotional labor that exhausts us.
But again, returning to the concept of compassion fatigue, but there's the deep well of energy and mood lift is in finding compassion for them. And so a lot of this emotional labor is reduced when we give up that need for the ego, and that doesn't mean in any way that we can't also maintain this narrative that the reason I've got a great job is because I love that sense of having helped my patient, and that is a necessary and essential part Of sustaining in our careers is that we have that narrative Yeah.
That's remembering the reward. [00:12:00] And I think when you said what you did about inside you're raging even though you're putting on the mask of caring, I think that was what you referred to as shallow acting versus deep acting, where you come to believe the behaviors that you're displaying, where you really come to internalize them and feel what you're projecting to the person.
Yeah. Technically, that is the language of emotional labor research, where they talk about shallow acting, which is just trying to act like I'm caring. Deep acting is more like method acting, where I'm actually trying to experience that, that felt sense of caring. But I think more than deep acting, it's about genuine, genuinely caring about them.
Which again, we can do when we really can successfully get that sense of this is about them and the way they are hurting. And, you know, when you talk about this party I'm having at my [00:13:00] house all by myself, you know, that part- You know, just need it to get to Salt Lake City. It'll take me a little while. But part of that stepping out of the echo chamber, whereas in the helping professions we've had these conversations about compassion fatigue, and speaking about compassion as if it is fatiguing.
How can I have compassion for patients when I'm seeing them every 15 minutes all day long? And we're assuming that compassion is draining, but while we're having that conversation, the sociologists who are doing the research on emotional labor are finding that every time you experience genuine empathy, there is a rising mood and a rising energy.
Yeah. And so it, it's about that disjuncture between viewing compassion. For one thing that we view compassion as if it's [00:14:00] time-consuming, I don't have time. I just recently completed a C-ERT training for a healthcare system where one of the E- ER docs talked about how transformative it was for her when she set a goal of having personal contact with every patient she saw in the emergency department.
Even as busy and crazy as it was, that her first order of business was to find a way to have personal contact with that patient that's in front of me. And that began to transform the experience of the workforce. Sure. But the reason we've had that idea that empathy was depleting ultimately comes down to effectively a poor boundaries.
That we need enough empathy to prime our feeling of compassion for that [00:15:00] client. But the chief stuff of compassion is kindness. Kindness feels good. The chief stuff of empathy can't be sadness or grief or the distress of the client. It must be the kindness that we're experiencing. And so I really view empathy as kind of melting our boundary so that we can get to where do they hurt.
Mm-hmm. And that once we get there, it is about reestablishing the boundary, that my goal is to look upon that hurt with kindness, but it's not to take on their suffering. It's not to feel it all. In my book, I quote T.S. Eliot with his, "Teach me to care and not to care." Hmm. The not to care, that's not an oxymoron, but rather the caring and the not caring are t- are twin dynamics of the same caring impulse, [00:16:00] and that you literally can't do the first, the caring part, if you can't do the second, which is learning how to establish a boundary and let the caring come to its natural conclusion.
This is the self other distinction that you talked about, that recognizing that the person suffering matters to you, but you are not the one suffering. You're not inside the suffering, you're next to it. I am the one who am feeling kindly towards he who suffers. Yeah. I love that. So you've actually brought me to my second question, which is that as we've talked about this term that you have taught us now is a myth of compassion fatigue, one of the things that people will often allude to then when they're talking about that is how hard it is to keep hearing the tragic stories and feeling the sadness that they evoke in you and saying, you know, "I can only take so much."
One of the studies that I teach to my students at the [00:17:00] University of Pittsburgh is from Nagoya University Medical School in Japan, where they interviewed med students and residents in sort of these focus groups about the different types of empathy that they felt. So there was emotive empathy, which is sort of the feeling I just described.
Cognitive empathy, which is being able to process, okay, I understand why this person is feeling this way in my head. Moral empathy, where you... Which is kind of adjacent to emotive because you get morally outraged, this is wrong, somebody should do something about this. And then behavioral empathy, which then results in people actually doing something about it, intervening in some way that- I think speaks of the kindness that you were talking about.
And what they found is that the med students were very high on the emotive empathy scale and didn't know how to move to the behavioral. And the residents were much lower on the emotive scale, but very high on the cognitive scale and much higher on the behavioral scale. So they were [00:18:00] cerebrally understanding, "Okay, I see why this person feels this way.
Let me do something for them that will make them feel better," and able to sustain this. I don't know if you're familiar with the book Compassionomics? I am, I am not, no. Well, I'll promote two books in one episode. Steve Dosiak and Anthony Mazzarelli, they are senior leaders at Cooper Memorial Hospital in Camden, New Jersey.
One I believe is an ER doc and the other is a critical care physician. And they wrote a book in 2019 that compiled essentially all the evidence that was in the published medical journals about the effect of compassionate behavior on people. And in their introduction, they talk about compassion as essentially behavioral empathy.
It's taking those feelings of empathy and enacting something with them. So I wanna back up from compassion for a second and say that I think we're talking about empathy when I ask this question, which is how do you, [00:19:00] when you're exposed every 15 minutes to tragic stories, I work in a clinic that is populated, about two-thirds of my patients are refugees from somewhere.
And needless to say, there's a lot of tragic stories that I hear every day. And you talk a lot in your book about what to do when you are being hit by wave after wave of sadness like that. And how do you get through your 8, 10, 12 hour day and then come back the next day for more? You m- you may be familiar with Margaret Moorman, who is a emeritus medical professor now, but she has this lovely saying about having your heart broken every day will not kill you.
It won't send you to business school, and it won't burn you out, but rather it is the heart that's unwilling to be broken that will not have the capacity to hold [00:20:00] what must be held at the center of good doctoring. And so it is a- again, about the twin skills of caring and not caring. You're adding to it when you talk about the behavioral empathy, that there's also the what do I do about it piece.
But I just wanna f- for now to focus the conversation, talk about the actual emotional experience of caring has to also include the not caring piece, that I think a lot of my CSER model has been informed first by my own observations. And one was in watching healthcare providers- In a pediatric oncology setting who were treating my own son, who I later lost to leukemia.
And in watching them, I've heard the phrase that they were such natural artists, they didn't even know the artistry they were demonstrating. [00:21:00] For instance, one of the RNs, a pediatric oncology nurse, I watched him meet with a family who had lost their child, and to weep with them in a wholehearted way, and only minutes later to witness him at the nursing station laughing and joking with the nurses.
Both of these were genuine responses. And to realize that I'm watching this kind of emotional agility, that's the caring and that's the not caring. And the reason it feels like I couldn't possibly do this all day long i- i- it really has to do... When I characterize it as ultimately a boundary, it's a boundary between their suffering and mine.
The reason I can't move to the not caring is because it's opened up now my grief. It's opened up my [00:22:00] sadness. If you have your three-year-old daughter's in her bedroom crying because the lightning and thunder is frightening her, you will go in and you will naturally have a great amount of compassion for her.
Mm-hmm. But you don't leave her bedroom then with your own fear of lightning and thunder. With, with young children, the boundary is so obvious that we don't get seduced to it. We do, however, have our own grief and our own sadness, and when that gets tapped, that's what we're protecting against ultimately, is we're really protecting our mood.
The mood that's underneath the emotions or the feelings up here. And when we develop enough skillfulness to have that kind of agility to metabolize the emotion without our mood being affected, it can happen very quickly and doesn't require a lot of time. I wanna come back [00:23:00] to how to develop that agility because you do talk about a lot of very specific moves that a person can make in their mind or with their physical behavior to get there, and I think those are tremendously important skills.
I just wanted to ask you, you dedicated your book to the son that you were talking about, to Jackson. Am I right? I did, yes. Thank you. Thank you for sharing that with us. Thank you. Thank you for noting that and for using his name. Always. So I wanna get to what I think is the greatest device that you have in this book, which is this beautiful mythic narrative that you have.
You talk about narrative as one of your devices- Speaking of ways to do the metabolizing o- of the emotion. But if I can summarize really quickly, and then you can feel free to expand as much as you want. It's this mythic tale of a person who enters the woods at the darkest place and retrieves the magic elixir, and then brings it home to the tribe that's gathered around the campfire, and you use [00:24:00] this to talk about creating a conscious narrative around the work that we do.
Now, I love narrative also, and I noticed a similarity to my favorite narrative structure which, as I told you, is the Passover Seder- Right ... with the story of the exodus from Egypt, of people being released from, uh, the narrow place of enslavement by a strong hand and an outstretched arm of God. And we retell this story around a dinner table, and we ask four questions, or they're also called in Hebrew the Ma Nishtana, the how different or what's so different about this?
Or I cynically say in my book, or the what else is new, which is kind of like your patients in the first story. One of those questions in the Seder, the third one, is about why we dip our vegetables twice, and both times that we're dipping, we're taking first time fresh greens and dipping them in salt water, and the second time we're taking this very bitter vegetable.
Often it's, in America we often use horseradish root. This year my family- Mm-hmm ... used the ginger root 'cause my wife couldn't find horseradish root for some reason. The [00:25:00] ginger was actually a great move. And dipping it into some kind of a sweet fruit concoction we call charoset, which I'll talk about in a second.
But it seems to me that the reason we're doing that is we're taking something that has a particular emotional valence and dipping it into something with the opposite valence. So the greens are this hopeful, springy thing, and we're dipping it into the tears of enslavement. And when we dip the bitter herbs, we're taking the bitterness of enslavement and dipping it into something sweet.
Although, asterisk here, the word charoset comes from the word for clay, and it's supposed to represent the mortar between the bricks 'cause it's so sticky. But let's just say that the sweetness does offset the bitterness. So what the commonality between the two is, it seems like your narrative and mine are both focusing on changing the story from a defeatist one into a constructive one.
Agreed. Yeah, strongly agreed. That my book is called Reducing Secondary Trauma, but it's intended the, the after the [00:26:00] colon part is as important to me, which is about sustaining a career in the helping professions. But, but secondary trauma isn't caused merely by exposure to intensity, not by exposure to trauma.
Trauma itself isn't caused only by exposure to the traumatic element. Trauma and secondary trauma happens when we feel overwhelmed or helpless The overwhelmed or helplessness, I'm gonna work up my way back to making that about the nar- which is what you asked me. But the narrative must support a view that we have mastery and that we are not helpless.
Mm-hmm. And so the narratives are very important to me. I need to credit the reference of Joseph Campbell and his monomyth. Mm-hmm. And in that monomyth- Mm-hmm ... that Campbell said that every hero story [00:27:00] begins when he, and I'm genderizing it because he did, and the classically was, when the hero chooses to enter the woods at the darkest place, which in my book is the introduction to the experiential engagement.
Or in Margaret Moorman's version about willingness to have our heart broken every day. Uh, about the very thing, another Joseph Campbell-ism about the treasure that we seek lies in the cave that we fear. In a very concrete way, you take the part of your job that is the most aversive to you, that you dread the most, that drains your morale the most.
That's where the treasure lies- Mm-hmm ... is by opening to that. And the treasure being that a meaningful, worthwhile career, that is what we were seeking when we entered helping work. [00:28:00] Yeah. So the narrative is important that the three-act structure of the narrative, just the before, the during, and the after, can represent the before when we chose our career, the during as we are experiencing the career, and the after as we tell the story of what that career represented.
The three, as you said, narratives themselves being conscious of our narrative, it, it's not only a tool within the strategies that I'm talking about, it's the load-bearing wall. And that what that narrative must, again, speaking, knowing that I'm speaking to a healthcare professional, we can tell the story rightly in that the story is that the healthcare occupations, healthcare industry is not built to support worker wellbeing.
It's not built to support the things you talk about and that [00:29:00] I talk about. And so within that, how do we maintain a narrative that isn't about being overwhelmed or helpless? And so every one of my C-CERT strategies is about putting you back in an active role as opposed to a passive victim being buffeted by the injustices of the system.
And you know, that's a pretty dense top- topic that probably goes further than you would want to in this short conversation Actually, Brian, the injustices of the system are exactly what I want to talk about. I want to know how we as a profession or I as a healthcare leader can ask my colleagues and employees to thrive in a system that works so poorly and so unevenly.
What do I need to do to create the conditions where they can implement Brian's recommendations successfully? Brian's answer to that question was so rich, I decided it deserved an episode all its own. So we'll pick it [00:30:00] up next time. Meanwhile, I'll leave you with a few thoughts about what we do when conditions don't lend themselves to being the best we can be.
The antidote to fire and to burnout is water. In Brian Miller's book, he doesn't describe the opposite of burnt out clinicians, the ones who are thriving in the water metaphor. He describes them as on fire, burning right. In other words, he describes them as the burning bush. Moses gets his first sign that he needs to go back and help his people from the burning bush.
Him going back and helping is a situation that pushes him to the edge of burnout many times, even to the point of asking God to strike him dead. We hear of the burning bush that the bush was not consumed by the fire. Why not? The medieval Spanish scholar Abraham Ibn Ezra tells us that the sneh, the type of bush that Moses sees, is a type of thorn bush that's always found in dry desert landscapes where the [00:31:00] water is deep underground.
A much older text, the Aramaic translation Targum Yonatan, doesn't translate the verse as the bush was not consumed, but the bush remained moist. Being on fire, in other words, is about digging deep underground to find a water source, leaning in, staying engaged in our work until we find the thing that will sustain that work.
How do we dig for water in this desert landscape? And what can I do to irrigate that landscape better? That's next time. Be sure to join us