By Anna M. Laucis, MD, MPhil
I sat in the back of the room, overwhelmed with emotion at the sight before my eyes. A young woman sat in front of me. Younger than me. A mother. She had 3 young kids at home, all under 4 years old. To her right sat her radiation oncologist and in front of him a computer screen dotted like a starry sky. I was only in college at the time, but I knew that the dots on the screen couldn’t be good news. There were many of them, some big, some small. These “stars” were in fact quite the opposite—each was a tiny brain tumor, a metastasis, spread from another site.
I watched helplessly as the mother sitting before me brought her fingertips to her forehead and then all of a sudden let out an anguished, visceral moan. The cancer had spread, and this was the moment she learned the bad news. I managed to awkwardly hand her a tissue box from the ledge next to me. I watched as she sobbed, shoulders heaving and stooped. And then, as if emerging from a fog, she looked up. She angrily wiped the tears from her cheeks and a gleam of sheer determination, evocative of the human spirit, began to glow in her watery eyes. As a tear rolled down her cheek, the ember in her eyes grew into a small flame that burned as she turned to her radiation oncologist and said, “I’ll do anything. I’ll drive here every day if I have to. I’ll shave my head. I have to be here for my kids.”
At the time, I was more in awe of the multi-million-dollar radiation therapy machines and flashy technology at the cancer center to fully grasp or even consider the downfalls of pinning hope too optimistically on scientific advances alone. What I did not know at the time is that I would have many future encounters like this on my own journey to become a radiation oncologist. I was inspired to pursue this field due to the ability to care for patients at their most vulnerable state, forge strong trusting relationships with them, and help them on their journey towards wellness, whether that means cure or palliation. In the case of this young mother with widespread metastases, eyes filled with hope and determination, I witnessed the art of medicine unfold and saw how it is the oncologist’s role to delicately balance patients’ expectations while also ever so gently bring them down to reality—if not at the initial consultation, then at the right time. Expectations that remain lofty and unrealistic only hurt that much more later on for patients if not addressed with poise and empathy in the setting of a trusting patient-oncologist relationship.
This brings me to the central issue of oncology health professional burnout. I learned early on, even before I was squarely on the path to a medical degree or residency in radiation oncology, that there is an emotional toll to cancer care. Time and again, oncologists absorb the collective anxieties, traumas, fears, hopes, and dreams of their patients. Yet, unfortunately, there is rarely an outlet in real time or even in the future to ever truly acknowledge or address any of those emotions with the patients or families involved. Or with other providers, for that matter. Precious time with patients is very limited in the clinic, and as oncologists we must press on and talk about the treatments and how we’re going to hope for the best but prepare for the worst. Our tremendous depths of knowledge, clinical trials data, and medical jargon are distilled and distorted into phrases easy for our patients to understand, such as, “Your cancer has spread.” What remains sometimes unstated, due to discomfort or assessing the situation and not wanting to completely crush the souls of our patients, are the words that are hardest to speak: “You will likely not be around for your young children,” or, “You should start planning your funeral.” These thoughts might cross our minds, but we set them aside, even though they are often sadly very true.
What seems to drive health professional burnout in oncology? In addition to the significant emotional burden we bear day in and day out from difficult conversations with patients (both what is said and what remains unsaid), there are the larger concerns of corporatization of health care, lack of autonomy, long work hours, and a general trend in today’s culture towards lack of respect and appreciation for physicians. It is true in oncology as much as any other field that there is an increased focus of health care as a “service” provided by “employees” (medical professionals) to “consumers” (patients). Patient satisfaction scores factor into salaries, hospital administrators dictate clinic schedule templates, insurance companies wield far too much power in treatment decision making with prior authorizations and coverage denials—all of which contribute to burnout. Professional burnout is defined as the triad of emotional exhaustion, depersonalization, and a sense of decreased personal accomplishment, or simply “a state of vital exhaustion” as defined by the World Health Organization.1 It is no wonder that burnout rates in medicine, and oncology specifically, are so high.
Physician Lives Are at Stake
A 2019 survey by Medscape on physician burnout, depression, and suicide showed that over approximately 39% of oncology physicians report high levels of burnout.2 There is a lack of formal data regarding oncology trainee burnout, but the Accreditation Council for Graduate Medical Education (ACGME) has had an increasing focus on resident and fellow burnout lately, including formal measurement of burnout rates among trainees using anonymized validated burnout questionnaires.3 This has motivated ACGME wellness initiatives including the “Back to Bedside” program, launched in 2018, which has awarded 63 project grants to a diverse group of residency programs at a number of institutions for resident-driven ideas to promote restoring joy in medicine.4
It is imperative that oncology residency and fellowship programs (surgical, medical, and radiation oncology) promote wellness as a core value and establish support systems to help their trainees, who are a particularly vulnerable population. In addition to work hour restrictions and other ACGME-mandated trainee protections, it is of utmost importance that oncology programs and leadership recognize the tremendous emotional burden of caring for patients with cancer and establish mental health resources to support trainees and faculty. It is not enough to encourage general self-care or offer yoga or fitness classes. What trainees and faculty alike could particularly benefit from is dedicated counseling time to have a channel for discussing some of the difficult emotional situations we deal with multiple times every day. Many programs might advertise that they offer mental health services, but a question arises of whether this is truly accessible to those who need it most. For example, are the office hours of the counseling service amenable to a busy 80-hour work week? Are weekend or evening appointment times available? It is affordable? If these considerations are unacknowledged, then the reality is an empty, inaccessible resource that has an appearance of support but lacks true substance.
Additionally, confidentiality is a huge concern. If mental health services are advertised as confidential but then the counselor notes are documented in the hospital electronic medical record where the person works, I would argue that it is not truly confidential. This is particularly worrisome in light of some state-specific mandatory reporting requirements in instances of suicidal thoughts. Suicide is the ultimate undesirable outcome from unaddressed burnout. In the 2019 Medscape survey on physician burnout, 14% of responders reported that they have had thoughts of suicide but have not attempted suicide, and 1% reported that they have attempted suicide.2 Even more worrisome, perhaps due to the stigma of mental health issues even among medical professionals, 64% of responders indicated that they do not plan to seek help for burnout or depression and that they have not sought professional care in the past.2 Clearly, this identifies a huge unmet need, and sadly, the end result is physician suicide. A May 2018 article highlighted this terrifying statistic: “One doctor commits suicide in the U.S. every day—the highest suicide rate of any profession.”5
Notably, burnout disproportionately impacts women, with over 50% of female physicians reporting significant levels of burnout compared to 39% of male physicians, according to the 2019 Medscape survey.2 Suicide rates also disproportionately impact female physicians, which is in stark contrast to the general population in which men have higher completed suicide rates than women. An ACGME resource states, “The suicide rate among male physicians is 1.41 times higher than the general male population. And among female physicians, the relative risk is even more pronounced—2.27 times greater than the general female population.”6 Women are already underrepresented in fields such as surgical and radiation oncology, and more must be done to keep them engaged in the profession, to keep them well, and to keep them alive.
In an aging population in which cancer burden is predicted to rise,7 we cannot afford any more oncology provider suicides. It is of critical importance to the future of the field of oncology, and we therefore must have a call to action to do more to address this pressing issue of burnout.
Amid all the doom and gloom, there are some reasons to be encouraged and inspired. The path towards wellness is possible. It all starts with acknowledgment of the problem, followed by addressing it through actions intended to provide support and outlet channels for discussion of some of these very difficult and deeply personal issues we all face as oncology professionals.
One example of a successful program that addresses physician burnout is the national platform called Schwartz Rounds, which was established in 1995 by Ken Schwartz, a patient with lung cancer, to encourage impactful caregiver-patient relationships and nurture compassion in health care through multidisciplinary discussion forums akin to group therapy and reflection.8
Personally, I was enthralled by the idea of Schwartz Rounds after attending many sessions in medical school and residency and was inspired to adapt this discussion platform to my specific field of radiation oncology. Within my own institution I have recently established a forum called “Radiation Oncology Reflection Rounds” where we have discussed topics such as meaningful patient interactions, featuring interdisciplinary perspectives from physicians, trainees, and other health providers in the department. Through this forum we also had a recent department-wide conversation on the controversies surrounding the bell ringing tradition in oncology, which is a topic of interest highlighted by radiation oncologist Dr. Matthew S. Katz in his February 2020 ASCO Connection commentary.9 Our departmental Radiation Oncology Reflection Rounds forum on the bell ringing tradition was so well-received that it motivated a separate focus group discussion on alternative meaningful ways to acknowledge patient milestones; the conversation will continue at institutional patient and family care meetings.
Establishing a safe and supportive environment that allows providers across our institution’s radiation oncology department to gather together and reflect upon difficult and often highly personal concerns has been a positive move in the right direction. And yet there is always more work to do. Wellness initiatives intended to support oncology providers must address the emotionally burdensome component of the work we do, for which there does not exist an easy or accessible channel for reflection (other than private counseling). Moderated group therapy-type sessions such as Schwartz Rounds or Radiation Oncology Reflection Rounds offer some ways to have this type of outlet. However, it is also important to consider how the little things might add up to influence departmental culture in the oncology setting. For example, if a bystander witnesses a difficult patient interaction or an unprofessional encounter between two oncology providers, it would be helpful to have a culture that allows for debriefing these challenging scenarios so that healing or at least reflection and validation can occur. We all must consider our own role in shaping a positive culture that centers on respect, civility, gratitude, and humility. Together we can support each other as oncology professionals so that we are best prepared (physically, emotionally, mentally, professionally, and otherwise) to take the very best care of our vulnerable patients with cancer.
If the roles were reversed, and I were the young mother sitting in the room many years ago, looking to my radiation oncologist to provide support, guidance, competence, and empathy, I would want that provider to be focused just as much on their own wellness and stability as my well-being. To be the best oncology health professionals for our patients, we must first take efforts to take care of ourselves. We owe it to ourselves, and we owe it to our patients and colleagues. Self-care is not enough in isolation, because ultimately we are not alone on this journey. Beside us and all around us are others who depend on us, sometimes critically so in order to save their lives, or sometimes just to be a caring colleague, mentor, and friend. We can all give our best efforts to support each other on the path to wellness.
Dr. Laucis is a radiation oncology resident physician at the University of Michigan Rogel Cancer Center Department of Radiation Oncology. Follow her on Twitter @annalaucis.
- World Health Organization. International Statistical Classification of Diseases and Related Health Problems. 10th Revision (ICD-10) Geneva: World Health Organization; 2004.
- Kane L. Medscape National Physician Burnout, Depression & Suicide Report 2019. January 16, 2019. Available at: https://www.medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056. Accessed 4 March 2020.
- ACGME Resident/Fellow and Faculty Surveys. Available at: https://www.acgme.org/Data-Collection-Systems/Resident-Fellow-and-Faculty-Surveys. Accessed 4 March 2020.
- ACGME Back to Bedside Initiative. Available at: https://www.acgme.org/Residents-and-Fellows/Back-to-Bedside. Accessed 4 March 2020.
- Anderson P. Doctors’ Suicide Rate Highest of Any Profession. Available at: https://www.webmd.com/mental-health/news/20180508/doctors-suicide-rate-highest-of-any-profession#1. Accessed 4 March 2020.
- ACGME: 10 Facts about Physician Suicide and Mental Health. Available at: https://www.acgme.org/Portals/0/PDFs/ten%20facts%20about%20physician%20suicide.pdf. Accessed 4 March 2020.
- World Health Organization Cancer Statistics. Available at: https://www.who.int/cancer/resources/keyfacts/en/. Accessed 4 March 2020.
- The Schwartz Center for Compassionate Healthcare. Available at: https://www.theschwartzcenter.org/programs/schwartz-rounds. Accessed 4 March 2020.
- Katz MS. For Whom the Cancer Bell Tolls – Or Should It? ASCO Connection 19 Feb 2020. Available at: https://connection.asco.org/blogs/whom-cancer-bell-tolls-or-should-it. Accessed 4 March 2020.