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Physician coach Nicole Perrotte and physician advocate and physical therapist Kim Downey discuss their article, “Love, empathy, and the triangle of exhaustion: Why humanity must come first.” Nicole introduces her powerful framework, the Triangle of Exhaustion, which describes the profound fatigue experienced by caregivers, physicians, and parents of atypical children. This exhaustion is composed of three parts: the emotional fatigue from constant advocacy, the social isolation from feeling alone, and the relentless responsibility of care with no off switch. Nicole and Kim argue that our society often makes empathy conditional, reserving it for those with a specific label or diagnosis. They propose a fundamental shift toward unconditional kindness. The conversation offers three actionable solutions to break the cycle: normalize differences, create judgment-free zones, and lead with love, providing listeners with a new lens for fostering genuine human connection.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Kim Downey. She’s a physical therapist and a physician advocate who brings together people across the health care spectrum. One of those people today is Nicole Perrotte. She’s a physician coach. Today’s KevinMD article is “Love, empathy, and a triangle of exhaustion, why humanity must come first.” Kim and Nicole, welcome to the show.

Kim Downey: Thank you.

Nicole Perrotte: Thanks, Kevin.

Kevin Pho: Kim, you are the author of a book that’s come out since we last talked, so tell us about that book.

Kim Downey: Thank you very, very much for asking. And also thank you very, very much for writing the endorsement on the back. I was so excited and proud when you accepted my request to do that. This is a beautiful book. It’s called White Coats Courageous Hearts: True Stories of Doctors Reclaiming Their Humanity in a System that Challenges It. I reached out to the first 20 doctors who were guests on my YouTube channel, and 15 of them contributed chapters. And the others wrote beautiful endorsements on the inside of the book.

I feel like this is a wonderful book for doctors and patients. You alluded to that right on the back. When doctors read it, they’re going to see themselves in these stories. They’ll feel validated, and when patients read it, they’re going to understand the struggles that physicians are facing and that we all need to support doctors. And Dr. Amna Shair recently wrote, “Physician advocacy equals patient advocacy.” And that is so true. It’s like if you advocate for your doctors, then they can advocate for you.

Kevin Pho: Wonderful. And thank you so much for elevating these stories. That really perpetuates one of the things that we talk about here: if physicians and clinicians or people across the health care spectrum are burnt out and struggling, how can they do their best for patients?

Kim Downey: A hundred percent.

Kevin Pho: One of these people that you brought together, Nicole Perrotte, she’s a physician coach. Kim, how did you find Nicole?

Kim Downey: Well, it is the way I find most doctors: on LinkedIn. We had connected over a year ago and we had a beautiful conversation. As you’ll get to see, Nicole is an amazing doctor, an amazing person, and I had her on my Stand Up for Doctors YouTube channel last summer. We continued communicating and now she’s actually helping me, a core team of doctors with others, you know, Dr. Cheah Chaffey, Dr. Michael Hirsh, and Dr. Charity Hicks. They’re helping me plan an epic physician retreat for the fall of 2026.

So we communicate more regularly. She knew that I was a pediatric physical therapist by training, and she reached out to me and shared with me her experience as a mom with an atypical child. Of course, through my work with countless children with special needs over the years, and I have relatives that are neurodiverse, so I could fully understand what she was saying. And I thought the message that she wanted to share was very important.

Kevin Pho: Nicole, you’re a physician coach. Your KevinMD article is “Love, empathy, and a triangle of exhaustion, why humanity must come first.” Tell us a little bit about yourself and then talk about the article that you and Kim contributed.

Nicole Perrotte: Thank you so much for that, Kevin, and thank you so much to Kim for highlighting some of the things that we’ve been doing over the last few months. It is almost a year already since we first connected. I’m a physician, internal medicine trained, and practice primarily as a hospitalist.

Everything was the usual go, go, go, go, go. We don’t think much about it. Yes, we expend a lot of time, we do sacrifice a lot, but we don’t think about it. It only came to a head when I had my children, and we already mentioned one of them has special needs and that required even more effort. It also carried that invisible burden that I talked about in the article because there are new challenges that are there when you’re raising a child who requires even more support and advocacy than you normally would have to on a regular basis.

Trying to put it all together, that led to burnout. It brought to light that there isn’t that much support. It isn’t talked about. It’s that invisible burden that a lot of my colleagues, our colleagues, are carrying with them. It’s push it to the side, let’s not talk about it. And there’s often that silence you have to bear alone that while this must be your fault, you need to do this burden and caring and lifting yourself. So it definitely contributes to burnout. A lot of my counterparts who are also in similar positions have found themselves having to step away from medicine and other fields as well, just because that burden becomes a little too much and they have to prioritize what’s important to them.

What I discovered is that having the fatigue, the emotional fatigue and burnout, combined with the isolation, and then just having to be responsible on a 24/7 basis could really lead to exhaustion and burnout. But once you’re able to advocate and manage your stress and find a community, that actually makes a huge difference. And that is where I was able to connect with Kim because she fully understood what I was saying based on her experience in her prior life as a physical therapist.

Kevin Pho: Nicole, you talk about that pressure to stay silent, the pressure to not share some of the things that you struggle with. So, how did you break through that wall of silence? What made you or what inspired you to overcome those burdens and share your story and speak out?

Nicole Perrotte: It’s very simple: it’s my son. I realized that if I did not advocate for him, no one was going to do it. I had to let myself put my own thoughts, my own fears aside of how I may be perceived, how I may look to others, and just do it. Because I realized at the end of the day, it’s for him. It’s not for me. Pushing past the fear, pushing past the silence, I realized I just needed to do this.

Kevin Pho: And Nicole, when you spoke out, advocated for your son, and also talked about your own exhaustion and burnout, what were some of the responses that you’ve heard from the community?

Nicole Perrotte: You get a range of responses. You get the empathetic, you get the ones who are sympathetic and pity, but you don’t necessarily want pity. You get the ones who try to offer support and try to understand, and then you get the ones who simply just ignore and pretend that you said nothing. You essentially get the entire spectrum of responses.

Kevin Pho: So Kim, when you first heard Nicole’s story, what about her story specifically resonated with you?

Kim Downey: Well, through my years working with many families that have children with special needs, I recalled actually being in the room with a parent receiving the diagnosis from a pediatric neurologist, the same diagnosis that Nicole’s son has. The doctor walked out and I was there with the mom who had just received a life-altering diagnosis for her child. Especially with my work with Birth to Three, you’re working with the families with their children.

You’re with them. I used to even work in the NICU, so when they were premature and then they would receive diagnoses. You’re with those families from the very beginning, just navigating, finding out whatever it is. And sometimes you know as soon as the baby is born, for instance, if they have Down syndrome. So I’ve walked the journey with countless families through whether it’s the stages of grief or even how family members and community members accept and respond. So all of that was powerful.

I’ve worked all the way up to one family who had two girls who in their early twenties, both in wheelchairs, and people would just have no idea. If you want to run to the bank, you just run to the bank. What if you have 21- and 22-year-old children in a wheelchair? They don’t realize the differences. It’s a whole different life. I fully understand that, and I wanted to support Nicole however I could, and that’s why I thought this article was so important.

Kevin Pho: The article talks about the triangle of burnout and the triangle of exhaustion. Nicole, can you just tell us a little bit about both of those?

Nicole Perrotte: Yes. The triangle of exhaustion, that is a term I came up with as I was doing my research for my TEDx speech. Essentially it’s the emotional fatigue that you’re dealing with, the constant thinking about solutions, thinking about problems, brainstorming, finding solutions, going through different appointments, finding services, navigating appointments, all of those just powering through constantly. Then, of course, there is that emotional toll that comes about because you’re wondering, “Well, what’s next? What does the future hold? How does this all pan out as the time goes by?”

And then there is the social isolation that comes because unfortunately, the community is small. With a new diagnosis, you’d often find yourself on the outside because you haven’t built a community with similar people who would understand what you’re dealing with. So you’re there, you’re doing it alone, and you’re not sure if anybody else will understand. But then you are also trying to be responsible. You’re trying to make sure you’re making the right decision. You’re trying to make sure that you’re also staying on top of your work. You’re trying to make sure that you’re balancing all of these things. And so it’s that triad of the responsibility, the social isolation, the emotional fatigue that will come together.

Kevin Pho: Nicole, I’m sure what you’re describing resonates with a lot of the clinician listeners who may be listening to you now and read your article on KevinMD. Tell us about some first steps that they should take to break out of that triad of exhaustion because this definitely sounds completely overwhelming, and a lot of physicians I talk to just simply don’t know where or how to start.

Nicole Perrotte: Right. The very first people to ask would be your therapist, your doctors, because they would often have other patients, they would have other families who would be in similar situations and could point you in a direction. They would say, “Why don’t you check this out? Why don’t you call this person? This person is a good resource. They could help you navigate this,” and they will be able to give you the next steps.

In so doing, you’re able to then connect with people. You may not necessarily form a bond immediately, but at least you’ll start realizing you’re not alone. And once you realize you’re not alone, that in itself takes away a huge portion of the burden because having that community where there is understanding of what you’re going through, of not trying to make your life look very normal when in fact, there are things that are different and it becomes your new normal, but it’s different. And so finding that community and building those relationships will be the first step.

Kevin Pho: One of the themes that I’m hearing loud and clear is the importance of connection and community. Nicole, you’re a physician coach. Can you share some stories about your clients who may have been facing that triangle of exhaustion and have found their community?

Kim Downey: Sure. It’s actually quite incredible. So everyone knows that I am Stand Up for Doctors, right? And what I do is stand up for doctors. Interestingly, some people might be surprised at this, some people might have initially been surprised that I talk to doctors all day, right? That once they do that, they might be equally surprised that I don’t just talk to doctors. So I thought today is a really prime example because this afternoon when we’re off this call, the people I’m talking with, one is a patient engagement speaker who wants to know how I broke into physician circles as a lay person. That’s evaded her her entire career.

So what I’m going to tell her is we need to flip this on its head. It’s because I really care about doctors and they know that I do. And maybe if we get some patient advocates to become doctor advocates, we can escalate how we’re all going to make a difference. So just my conversation with her could really have a big impact. And then I’m speaking with a doctor who’s just curious about what I do, and I don’t know where that’s going to go. So eventually she might be on my YouTube channel. And when I talk to a doctor, I seem to know who they’d want to be connected with. Even speaking to this today is Nicole, I believed after we wrote this article that I connected you with Dr. Don Sears, right?

Nicole Perrotte: You did. You did. Yes.

Kim Downey: And Don wrote a beautiful chapter in our book, and it’s called “Delayed: Navigating motherhood and medicine.” Don Sears shares in this book, you know, you give up your twenties and all that to the practice and medicine. You’re working really hard and she too has a child with special needs. She talks about the short bus and you know, that’s when you have a child with special needs. Oftentimes it goes around town and picks up those kids and just what a different life it is and how she navigated it. So since I’ve known Don and had conversations with her, I was able to connect them.

Then I am speaking to someone whose job is influencer marketing. He’s inviting me to share my expertise with his company’s audience, so I have to be careful because some people want to use me for my connections. I have been burned a few times and I’ve discussed it with Dr. Michael, my physician coach, but he is like, “Well, most people mean good and you can’t limit yourself too much because then you miss out on opportunities.” So I constantly have to balance that myself. But he’s not a doctor. Right? But if I could get my message out with a wider audience, because if this book just circles in LinkedIn circles, you know, then the messages won’t get out to so many doctors and patients that need to hear about this.

So even if it’s a little scary or awkward, uncomfortable for me, I have to be willing to have conversations with all kinds of people. And then I’m also speaking with someone whose mission is normalizing mental health at work. He’s finishing a book on his experience and learnings as an executive at Kaiser, while also struggling with undiagnosed yet severe depression and anxiety. And as you know, I’m an ambassador for the Dr. Lorna Breen Heroes Foundation. And I’m doing this work because my own doctor took his own life. So I am very interested in hearing what he has to say. And then even just yesterday, I connected, there’s a nurse who’s forming a survey to help other nurses with their workflow or something. And I’ve connected with a number of nurses, so then I connected them in a private message and now they’re connecting with each other. So that’s just a few examples.

Kevin Pho: One of the themes that I’m hearing loud and clear is the importance of connection and community. Nicole, you’re a physician coach. Can you share some stories about your clients who may have been facing that triangle of exhaustion and have found their community?

Nicole Perrotte: The community doesn’t have to be medicine. It doesn’t have to be the people you work with in the hospital or in the office. One of my favorite stories is this burnt-out hospitalist who after the usual college residency, she’s an attending who was working nonstop and had no hobbies. One of her hobbies was opera singing, and she didn’t have a community of singers where she worked, but she decided after a couple of months of coaching to actually start looking at opportunities for that, and she found one a 45-minute drive from where she lived.

The change in her that came about once she found that community was unbelievable. At the end, she actually signed up for lessons and sent me a video where she was participating in a recital. The confidence that came through, the sense of “I am here. I am well,” was so overwhelmingly different from the woman that I met several months prior. That was one of my favorite stories.

Then there are also the ones who find themselves in really toxic work environments and thinking that they don’t have a choice, but then decided, “OK. I remember I was happy when I stayed at the beach, for instance, or in a bigger city. I’m going to take a chance.” And so one of my other clients, she decided, “I’m going to take a chance and I’m going to uproot my life of the last 10, 15 years and I’m going to move to this new city.” And it just fell in place. Everything landed in place. It’s a job, community, activities. By the end, she was going out, she had made new friends. Everything was a complete 180-degrees difference.

And so it is just having that person in your corner who could say, “What is it that works for you? What is it that will make you happy? What is the thing that you value at this stage in your life that will make a difference? What is the connection that you’re seeking that you don’t have right now?” And those are some of the things that a coach could help you find. When you’re sitting, you just keep thinking the same thoughts over and over. “Oh my gosh, I’m stuck. I have nowhere to go.” As opposed to, “There are options. Let’s really dig and unpeel the layers of the onion to figure out what it is that you’re looking for that you don’t have right now.” And so there is always that possibility out there. What is it that you’re looking for? Where can you find community, a judgment-free zone where you could be yourself, where you could actually find that balance between what you love doing, as well as doing the work that we spent so many years studying for?

Kevin Pho: We’re talking to Kim Downey and Nicole Perrotte. Kim, as you know, is a physician advocate. Nicole is a physician coach. Their KevinMD article is “Love, empathy, and a triangle of exhaustion, why humanity must come first.” I’m going to ask each of you to share some take-home messages for the KevinMD audience. Nicole, let’s start with you.

Nicole Perrotte: Thank you. Thank you so much for having me here. My reminder to the audience is every day you get a chance to start over. What is the value that you’re carrying most dear to you right now that will make an impact in your life? What is the thing that will make you happy? What is the connection that you’re missing? And once you’re able to remember that you get a chance to rewrite that chapter, then there’s no reason to sit back and say, “I’m stuck. I have no options.” Find that connection. Find that thing that makes you happy. Look for meaningful connection. Lead with love, lead with empathy, and it’ll all come together.

Kevin Pho: Kim, we’ll end with you. What are some of your take-home messages?

Kim Downey: Sure. Well, first, I hope everyone reads this article if you haven’t yet, because Nicole just does such a beautiful job. When she outlines the triangle of exhaustion with emotional fatigue, social isolation, and relentless responsibility, she makes the analogy both with parents of children with special needs and with physicians in the ways that each of them can experience these things, and that message will really resonate. I’m sure it will.

And just for Nicole herself, my gosh, you know, just being a doctor is hard. And then I’ve heard now of the extra layers female physicians face, and then when you’re a mom, and then to be a mom with a child with special needs. Right? All of those layers is really, you know, the fact that she has been functioning, but that’s why everyone needs support. I just feel like when she’s talking about connection and to stay curious and that we just need to be curious about each other. I know sometimes if doctors think health care leaders don’t understand them, well, maybe you could try being curious. Like maybe they have special needs kids at home. So if you just ask a question, and again, some aren’t open to it. All the doors won’t be opened.

But sometimes one small question… Dr. David Ey shares in his book, his chapter is on substance use disorder and anesthesiologists, and he has a powerful story about just his question or comment or being kind to an anesthesiologist going through that changed the trajectory of that doctor’s whole life. And actually the other, well, it was a nurse anesthetist, feels like Dr. David Alfre actually saved his life by just saying one kind sentence. You just never know how much it’ll mean. So just in the title, if we can all have love and empathy for each other and see each other as humans.

Kevin Pho: All right. Kim and Nicole, thank you so much for sharing your insight and perspective. Thanks again for coming on the show.

Kim Downey: Thank you so much for having us.

Nicole Perrotte: Thanks for having us, Kevin.