Many times, our patients are critically or terminally ill and in very difficult situations, and we are right there with them. But to effectively care for them, we need to take care of ourselves first.
—Sandra Sanchez-Reilly, MD, AGSF, FAAHPM
A variety of studies, including one published this past year in the Journal of Clinical Oncology,1 have showed that clinicians who care for seriously ill patients are at high risk for diminished personal well-being, including high rates of burnout; moral distress, defined as the inability to act in a manner consistent with one’s personal and professional values; and compassion fatigue, in which physicians experience diminished emotional energy to care for patients.
One key approach to mitigate the distress and grief oncologists and palliative care specialists often experience when caring for terminally ill patients is to engage in self-care, according to Sandra Sanchez-Reilly, MD, AGSF, FAAHPM, Professor, Palliative Medicine Section Chief, and Director of Palliative Medicine at the University of Texas Health Science Center at San Antonio; and Interprofessional Fellowship Program Director at the South Texas Veterans Health Care System. She is also the lead author of the article “Caring for Oneself to Care for Others: Physicians and Their Self-Care,” which appeared in The Journal of Supportive Oncology.2
“Many times, our patients are critically or terminally ill and in very difficult situations, and we are right there with them,” said Dr. Sanchez-Reilly. “We are always in crisis mode, but to effectively care for our difficult patients, we need to take care of ourselves first.”
The ASCO Post talked with Dr. Sanchez-Reilly about the factors that place oncologists at risk for diminished personal and professional well-being as well as the self-care tools and strategies oncologists can use to improve their overall well-being.
Self-Care Rounds and Retreats
Please talk about how oncologists can promote and maintain well-being while caring for patients with life-limiting cancer.
Taking care of patients with advanced cancer is very difficult and all-consuming, often leading oncologists and palliative care specialists to experience distress and grief in response to their patients’ suffering. Unless recognized and dealt with, these emotions can compromise clinicians’ well-being and lead to burnout, moral distress, and compassion fatigue.
So, the first thing is to recognize that we actually need to take care of ourselves, which we often don’t do well, and to understand that we are human beings, and it is natural to experience feelings of sadness, frustration, and anger when we lose a patient.
Here at the University of Texas Health Science Center, we encourage physicians to use self-care strategies to maintain personal well-being throughout their professional lives. We also hold self-care rounds twice a month to give the medical staff an opportunity to talk about how their professional lives are affecting their personal lives.
During these sessions, the staff may present case stories and explain how a specific patient situation is impacting them. For example, younger professionals tend to have a difficult time taking care of their younger patients with advanced cancer, because they identify with those patients. Or, a clinician may have lost a loved one to a particular cancer and finds that taking care of a patient with a similar diagnosis is difficult.
Other issues, such as problems with time management, are discussed as well. Making patient decisions takes a lot of time, not only to see and treat the patient, but to document those decisions and meet the requirements from the different hospitals or health-care systems that may be involved in that patient’s care. There may also be issues surrounding coordinating care within the various medical teams in the hospital as well as dealing with family members. Sometimes, there are disagreements between oncologists and family members or the palliative care team members and oncologists, and these disagreements can be cumbersome to deal with.
In addition to our twice-monthly sessions, once a year, we have a self-care retreat held somewhere outside the hospital to get away from our work environment and give participants a chance to focus on themselves. During the retreat, we discuss how to take care of ourselves so we have more energy and dedication to bring to the care of our patients.
The Wellness Wheel
What are some self-care tools oncologists can employ to mitigate the stresses in their professional lives?
Personal self-care refers to activities that are performed independently by individuals or a team to promote and maintain well-being throughout their professional lives. Some of those activities may include maintaining a healthy lifestyle through regular exercise, getting enough sleep, eating a healthy diet, and taking vacations; practicing mindfulness meditation; spending time with family and friends; and pursuing spiritual development if that is personally significant.
One instrument clinicians may find helpful is the Wellness Wheel (www.vanderbilt.edu/recreationandwellnesscenter/wellness/wellness-wheel). It includes seven areas of wellness to integrate into one’s life: physical, spiritual, social, emotional, intellectual, environmental, and occupational, depending on one’s specific needs.
Burnout, Moral Distress, and Compassion Fatigue
What are some consequences of experiencing burnout, moral distress, and compassion fatigue?
The symptoms and consequences are similar for all three. The one that has been most closely studied is burnout, which refers to a feeling of emotional exhaustion and may be associated with both high job turnover and poorer health. It is also linked to patient-related outcomes, such as medical errors by physicians and lower patient satisfaction, as well as unprofessional conduct and less altruistic values.
Less is known about moral distress and compassion fatigue, both of which can lead to burnout, but physicians experiencing moral distress may have increased irritability, decreased job satisfaction, insomnia, headaches, high blood pressure, and depression.
Compassion fatigue may manifest in symptoms similar to post-traumatic stress disorder, including hyperarousal and reliving events, such as clinical encounters with suffering patients or family members.
Are all oncologists at risk for developing burnout, moral distress, and compassion fatigue?
It is not only oncologists who are susceptible to these problems. Every health-care provider is at risk for developing these syndromes. In oncology, there is a more than 30% chance providers will experience these symptoms sometime during their professional lives. Physicians in emergency medicine have more than a 50% chance of experiencing burnout.
Finding Middle Ground
To avoid these problems, would it be helpful for oncologists to maintain some emotional distance from their patients?
I would say no. Physicians need to feel empathy for their patients, and if they are emotionally distant from their patients, they won’t. Physicians have to find middle-ground territory, which is difficult, but that is where employing the elements in the Wellness Wheel can be helpful. It is important to maintain a balance in one’s physical, emotional, professional, social, and spiritual life to reduce the chances of stress and burnout.
Strategies for Self-Care Needed
Current evidence shows that medical students, residents, and fellows receive inadequate self-care training. What can oncology professionals do to initiate personal and professional self-care?
The Accreditation Council for Graduate Medical Education (ACGME) has incorporated some areas of self-reflection into its hematology and medical oncology fellowship program requirements, but the program does not specify strategies to accomplish individual or team-based professional self-care.
Some examples of strategies for improving individual professional self-care include regularly appraising all aspects of work life; developing a network of peers and mentors; seeking organizational engagement opportunities; improving communication and management skills; increasing self-awareness in setting limits; prioritizing personal relationships with family members and close friends; and pursuing reflective writing.
Strategies for improving team members’ well-being include enhancing their skills to empathize with others; formalizing structures, policies, and procedures to guide team meetings; and sharing personal and professional sources of meaning and incorporating them into daily life. ■
Disclosure: Dr. Sanchez-Reilly reported no potential conflicts of interest.
1. Shanafelt TD, Gradishar WJ, Kosty M, et al: Burnout and career satisfaction among US oncologists. J Clin Oncol 32:678-686, 2014.
2. Sanchez-Reilly S, Morrison LJ, Carey E, et al: Caring for oneself to care for others: Physicians and their self-care. J Support Oncol 11:75-81, 2013.
Education in Oncology focuses on faculty development, medical education curricula, fellowship training, and communication skills. The column is guest edited by Leora Horn, MD, MSc, Associate Professor of Medicine, Assistant Director of the Educator Development Program, and Clinical Director of the Thoracic Oncology Program at Vanderbilt University School of Medicine, Nashville.