ONCOLOGY MOST STRESSFUL OF SPECIALTIES

Oncology is one of the most stressful of all medical specialties, and among the healthcare professionals on the cancer care team, oncologists are at highest risk for burnout.

Highlighting these issues and outlining some strategies to protect against burnout here at the 18th World Conference on Lung Cancer (WCLC) was Dr Maria Flanou, clinical psychologist at the Peter MacCallum Cancer Center in Melbourne, Australia.

"My role is to provide psychological services to people with cancer across the whole cancer trajectory, from diagnosis to end-stage disease," she said. As part of a multidisciplinary team, the work is "very rewarding, but working in oncology is also very stressful."

The stress in oncology stems from the nature of the disease that is being treated. The work involves repeatedly breaking bad news to patients, witnessing patient deaths as well as severe reactions to and adverse events from treatments, watching patients deteriorate session by session and seeing their physical suffering. In addition, "we often have to manage very complicated situations," she added, which can include encounters with angry patients or angry families.

In addition, there are increasing demands that take up time, and there are often staff shortages, "so it can get to 3:00 pm before realizing that we haven't had lunch" she said.

Together these factors can lead to burnout, she warned. This is often described as complete emotional and physical exhaustion, but there are other elements, including depersonalization (feeling detached, cynical) and having a low sense of personal accomplishment (feeling unfulfilled and unsatisfied by work).

There are very few personal accounts of burnout in the literature, she noted. "None of us ever wants to admit that we are not coping and that we can't manage our workloads," she said. In addition, admitting to experiencing burnout can jeopardize future job chances.

However, she did find in the literature two cases in which oncologists had written about their experiences of burnout.

"Time is baffling. It seemed like just yesterday that I sat in a posh auditorium in Chicago, an enthusiastic young adult on my first day of medical school orientation.... Eighteen years later, I was a 43-year old burned out physician, searching Google for the most effective way to end my life. During my time of maximum burnout, I was the type of physician that I never wanted to be: impatient, sarcastic, and occasionally dismissive of my patients." (Murphy, 2015)

"I go through weeks where it's very difficult to come into work. I come in but I don't really want to be here at all. It's an effort to drag myself down to clinic.... because I know that I'm going to see patients who are going to do badly." (Granek et al, 2012)

This second quote comes from a study published in the Archives of Internal Medicines. That article has many other quotes from oncologists who talk specifically about the impact of seeing their patients die.

Sometimes I'll take a chart and I'll look at the imaging, and everything's worse and the numbers are worse, and I have to drag myself into the patient's room and figure out what can I offer them that's hopeful and positive. It's tough." 

"Let's face it, people who go into medicine have full-blown fantasies, I mean, I do. You think you're going to go in there to cure people...and it doesn't happen. It doesn't matter what you do really.... Sometimes I make an impact on what happens but sometimes I just get steamrolled." 

"There's always sadness with every loss."

"Sometimes I cry. I cry on the way home in the car." 

"I think you just get exposed to so much death that you just become somewhat accustomed to it.... It's part of our job. I mean death is normal, everybody dies, it's just that we experience a larger amount of it." 

"It keeps me awake at night." 

"It is a very bad thing to become emotionally attached to your patients, because you're going to suffer." 

"It's something bad, but I have to keep my personal feelings and personal life separate from my work feelings and work life. I have to keep reminding myself to have a little bit of dissociation like that, so I can sleep every night and not carry things home." 

"The issue with doing Oncology is that you walk a very fine line; if you get too involved with your patients you can't function because it's too much emotional load to bear, and if you get too distant from your patients then I don't think you're being a very good physician because people pick up on that." 

"I'm up to the point where I probably lose one or two patients a week minimum. And that's a lot of people.... It's a physical sensation of being ground away.... It takes me a long time to recover from that." 

The authors write that as far as they are aware, this study is the first qualitative exploration of the nature and impact of grief in oncologists. "We found that for oncologists, patient loss was a unique affective experience that had a smokelike quality. Like smoke, this grief was intangible and invisible. Nonetheless, it was pervasive, sticking to the physicians' clothes when they went home after work and slipping under the doors between patient rooms."

Oncologists Most Vulnerable

In the literature, estimates of the prevalence of burnout among oncology professionals are from 35% to 60%, Dr Flanou noted in her talk. A random sample of 1000 US oncologists found that 56% had experienced burnout at some point in their career ( J Clin Oncol . 1991;9:1916-20).

Even higher rates have been reported ― a survey conducted by the European Society of Medical Oncology in 2014 found that 70% of young oncologists reported feeling burned out. Three of these oncologsts discuss their experiences in a Medscape report; they conclude that "there is no such thing as work/life balance."

Among the cancer care team, oncologists are at highest risk, Dr Flanou noted. She cited a study from 2014 that found that 38.9% of oncologists reported burnout, compared to 20.8% of nurses, 22.2% of specialist nurses, 20.9% of social workers, and 13.8% of psychologists.

"It is the physicians who are the most vulnerable to burnout, and I think this is because they have to be everything to everyone and perform a number of different roles in their workplace," she commented.

There can be serious consequences from burnout ― both for the healthcare professional who experiences burnout and for the patients under their care, she warned.

Among individuals who are experiencing burnout, it is likely that 20% to 33% experience mental health problems; 34%, poor quality of life; 30%, impaired intimate and social relationships; 15%, suicidal ideation; and 15%, drug and/or alcohol abuse problems.

Physicians who are experiencing burnout have less empathy for their patients, may offer reduced quality of care, and may make medical errors, particularly in drug dosing.

On the organizational level, burnout leads to increased absenteeism, high staff turnover, poor service delivery, and increased legal costs.

Importance of Self-care

The first step in addressing burnout is to measure it, Dr Flanou told the audience here.

The most frequently used tool to determine rates of burnout is the Maslach Burnout Inventory. This is a 22-item self-report questionnaire that measures the three distinct dimensions of burnout: emotional exhaustion, depersonalization, and personal accomplishment.

There are steps that can be taken to reduce burnout, both at the individual and organizational levels.

"Developing personal resilience is essential for combating stress and burnout," she said.

"Resilience is not something that we are born with, it's something that we need to develop," she continued. It involves "adapting well in the face of significant stress."

Four components help build resilience:

"Often these are the things that we neglect when we are most stressed," Dr Flanou commented, but these are the things that we need to make time for, because they help with coping with that stress.

Within the workplace, ways to build resilience including the following:

"Debriefing is vitally important," she said. "We have had patients who have gotten under our skin or who have died in traumatic ways, and making sure that we reflect on this with even a couple of people helps to deal with the stress."

Mindfulness ― being in the present moment, rather than worrying about what could happen or what has happened ― is very useful for coping with stress and for dealing with patients, she said. Mindfulness programs, which are usually run in group sessions, change one's awareness of how one feels emotionally. They can include breathing and stretching exercises and understanding stress. Several studies have shown very positive benefits from such programs for clinicians. These studies have found that participants in mindfulness training programs sleep better, cope better, and have increased empathy for their patients, she noted.

Communication training has also been shown to be beneficial, especially in helping physicians to break bad news to patients, which is one of the most stressful aspects of the job. These programs, which often involve role playing, are facilitated by mental health professionals. They have been shown to increase oncologists' confidence in delivering difficult information, she noted.

Dr Flanou has disclosed no relevant financial relationships.

18th World Conference on Lung Cancer (WCLC). Abstract MA 21, presented October 19, 2017.

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