Burnout recommendations reflect complexity of care, ‘humanity of being oncologists’
Physician burnout is common in all aspects of medicine.
The problem is particularly prevalent in oncology due to multiple factors, including increased expectations of personalized care, the challenges of working in a multidisciplinary team, and the personal investment oncologists make in their patients.
“Fundamentally, the field of oncology is high touch, and the patients have lots of distress,” Arif H. Kamal, MD, associate professor of medicine at Duke Cancer Institute, said in an interview with Healio. “A diagnosis of cancer is a life-changing event, living with cancer is a life-changing event, and even being cured of a cancer and moving toward survivorship is a life-changing event. We make the analogy that being around such distress without internalizing or being affected by some of it would be like thinking you can stand around a waterfall without getting a least a little bit wet.”
Kamal and colleagues on ASCO’s Ethics Committee published an article in JCO Oncology Practice that examined the causes of oncologist burnout and offered recommendations for addressing and reducing burnout. He spoke with Healio about the sources and manifestations of physician burnout and how to alleviate this burden so oncologists can continue to provide quality care to their patients.
Question: Can you describe the unique burnout challenges specific to oncologists?
Answer: There are several components to why burnout is a particular concern in oncology. The first is the cognitive load placed on oncologists to provide the most up-to-date personalized care. The unprecedented pace of FDA drug approvals over the past 5 years is fantastic for our patients and for the field, but also presents a challenge to clinicians who are trying to provide high-touch care while keeping in mind all the different therapeutics available.
As an oncologist, to discuss treating conditions that just a few years ago would not have had many options is exciting. At the same time, we are rapidly learning which patients with which conditions will respond to which medications. That means we must temper the scientific excitement with the reality that not all patients will respond. So, in talking with patients and families, we need to acknowledge the potential for positive outcomes but also discuss the uncertainty about response and prognosis. It is difficult, because you’re negotiating the hope that fantastic things might happen vs. the worry that they may not.
Of course, oncologists care a great deal about the lives and the outcomes of patients and their caregivers. When we are asked to be present for the distress of others, we sometimes see ourselves in our patients or their family members. We try to maintain a professional distance while recognizing that we are looking at another human being who is suffering from an event that we could suffer from someday. That can be tough.
Q: How might the multidisciplinary team approach lead to burnout?
A: Oncology care is, by definition, team-based care. We work in complex organizations where we collaborate with pathologists, radiologists, surgeons, radiation oncologists and others. This can present challenges for an oncologist, because to move forward you have to move together, and to move together you have to be able to work through complexities, disagreements and conflicts if they arise, as well as come to a mutual understanding of the right plan. However, functioning in teams also means we’re able to lean on each other as professionals for the normalization of these experiences. Many oncologists have moments of feeling as though their tank is empty, and it’s helpful to know that colleagues who are as passionate, accomplished and driven as you are also have those moments. Being able to normalize that — to view it not as a failure, but a consequence of the complexity and uncertainty of the field — is very valuable.
Q: What are some approaches oncologists can take to reduce burnout?
A: One strategy that oncology groups have found helpful is to create safe spaces for reflection and sharing. These allow you to renew a shared sense of meaning and purpose as a team, and get some of the things you’ve been thinking about off your chest. These are not case reviews. They’re not multidisciplinary conferences dedicated to treatment decision-making. They are about taking a moment to reflect and renew. Sometimes that can be a social occasion; other times, it can just be moments of truth and honesty together.
Q: How does ASCO aim to address oncologist burnout?
A: Fundamentally, our goal is to prevent a problem before it occurs. In our paper, we mention the ASCO Quality Training Program, which is a fantastic in-person and distance-based quality improvement learning program.
ASCO and others in oncology have an amazing opportunity to complement their quality measurement infrastructures, like the Quality Oncology Practice Initiative and other initiatives like CancerLinQ, to include one or two quality measures to assess what practices are doing to prevent burnout. These could be structure or process measures and potentially outcome measures. Structure measures may include a program at an oncology practice to address clinician burnout, such as through reflection groups or debriefing sessions. Process measures might include regular assessment of burnout and resilience issues or teamwork issues within a practice.
In the same way we assess how we’re doing in patient care, we can review how we are doing as individuals and professionals by checking in to see how burnout may be affecting our practice. Those measures and guidance don’t exist now, but I think they would be welcomed.
Q: How can oncologists begin to feel more comfortable acknowledging and addressing burnout?
A: We need to continue to recognize that burnout is not a personal failing, it’s a reflection of the complexity of care we provide and the uncertainty of the times we’re in. There is so much opportunity, yet we are challenged by that opportunity. It’s the anxiety that comes from so many choices.
Another problem is that, particularly in cancer treatment, we have used very aggressive language implying that anything short of winning is considered failure. We have described cancer as a “war” and patients as fighters. We have talked about oncologists as the saving grace or fixers of the problem. Sometimes, though, we can’t fix it.
As oncologists, we are problem-solvers by nature. Most of our interactions with each other are to discuss problem-solving for our successes. The nature of a scientific presentation is to tell others about the things that work. The nature of a case conference is to problem-solve together. I think a third leg to that stool can be professional interactions where we discuss the humanity of being oncologists. We can focus on progress, we can problem-solve together, and we can recognize that our profession is both difficult and rewarding — and that we can help each other through these challenges.
For more information:
Arif H. Kamal, MD, can be reached at 20 Duke Medicine Circle, Durham, NC 27710; email: arif.kamal@duke.edu.
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