“Few physicians deal with death and grieving as often as oncologists,” says Laurie Lyckholm, MD, of Virginia Commonwealth University School of Medicine (Richmond, Virginia). Frustration with limited treatment success and continuous exposure to fatal illness make oncologists particularly vulnerable to stress and burnout. To help avoid these detriments to personal and professional health, oncologists and their staffs should pay attention to the signs and symptoms of stress and follow some practical tips and suggestions for promoting emotional well-being.
Grieve Losses
The failure of treatment and the loss of patients are especially difficult for oncologists to deal with, and natural grieving is important. “You need closure. You should grieve in your own private way and it helps to grieve with the family,” says Lyckholm, who has made several presentations about burnout among oncology professionals and who wrote the module on stress, burnout, and grief for ASCO Curriculum: Optimizing Patient Care—The Importance of Symptom Management.
Jimmie Holland, MD, of the Department of Psychiatry and Behavioral Sciences at Memorial Sloan-Kettering Cancer Center (New York, New York), has also extensively studied burnout among health care professionals. “After a patient dies, it is important to talk with the family and answer any questions they have about the illness and death,” she says. “A call to the family at home or a note expressing your condolence means a tremendous amount to families—the absence is often interpreted as not caring, which is not the case at all.”
Holland adds, “In terms of your own survival, it is important to recognize that the death of some patients can affect you much more deeply than others. You can often recognize a resemblance in appearance or age or temperament of the patient that reminded you of someone in your past, and you can see why the death affects you so much more deeply.”
Manage Time
Death and grief are substantial stressors, but not the only ones. Holland points out that the era of managed care mandates short patient visits and an increasing amount of documentation, both of which diminish the time available to talk with patients or to have more recreation and time with family. Time-management tools and organizational techniques can help alleviate daily stress that can lead to burnout.
The first step, according to Lyckholm, is “delegate—enlist more help from your staff.” She explains that it is difficult for physicians, who have tendencies toward perfectionism, to delegate even simple tasks, but it is important to do so. “Not only does it make time for those tasks that can be done only by the physician but it also validates the contribution of the special skills of other team members,” she says.
Another tip, says Dr. Lyckholm, is to develop written plans for patients. “You can save about 5 minutes per patient and, at the same time, increase patient satisfaction and provide documentation of time spent with patients.” She offers some additional advice:
Look at your patient list a few days in advance to make sure you are prepared time-wise.
Plan every day the night before.
Make arrangements with your staff about how to handle interruptions.
Categorize tasks: Focus on what is important, not merely time sensitive.
Lyckholm also advocates removing paper clutter. “A clean and clear environment reduces stress by itself. If you spend just 10 minutes each day to weed out part of one of your stacks of papers, after about 2 to 3 weeks, you will no longer have stacks.” She also suggests cutting down on “virtual” and electronic clutter. “Ask to have your name removed from extraneous e-mail lists and answer e-mails as you go and then delete or file them,” she says. “Also, check your e-mail only once or twice a day. E-mail creates a sense of urgency, but most communications are not all that urgent.”
Preserve Well-Being
Oncologists must also foster their own emotional well-being to help alleviate stress and burnout. Holland points out that taking time away from clinical care and maintaining other interests is essential. “You should respect your recreation dates like patient hours,” she says.
Lyckholm concurs: “Plan your days, and make time for relationships, exercise, sleep, rest, and laughter.” Both physicians note that other tools such as meditation or prayer, reading (literature, philosophy), and writing (poetry, personal journaling and essays) can provide helpful outlets.
Recognizing limitations is another important point, says Holland. “You can't take yourself too seriously.” Lyckholm adds, “You should have a positive internal dialogue. You can't be too self-critical, and you need to realize that you can only do what is humanly possible.”
Maintain Relationships with Colleagues
Both Lyckholm and Holland note that sharing feelings with colleagues is integral to coping with stress. “It's important to remember that you're not alone,” says Lyckholm. “Communication of sadness, frustration, and grief is essential.”
Through sharing their feelings, oncologists may recognize serious indicators of stress and burnout in colleagues. Holland notes, “Showing concern when colleagues exhibit symptoms of stress and helping them obtain assistance is necessary to avoid a decline in the quality of patient care.” She adds, “It's also important to monitor staff morale. Low morale spreads quickly; you want to avoid burnout of the entire team.” (Holland describes several informal, proactive steps for managing stress in a practice setting in the sidebar.)
Lyckholm offers one final word of advice. “Remember how much value there is in what you do, and how much you are valued. Every day, you directly and indirectly affect tens and hundreds of peoples' lives.”
Ways to Manage Stress in an Oncology Practice.
Make time regularly to reflect on and have casual discussions about stress-related issues
Set up a special lunch to talk about patients and reactions to them
Hold special gatherings to celebrate progress
Conduct medical team meetings for problem solving and conflict resolution
Offer sessions on delivering bad news, managing difficult psychological problems, and understanding cultural factors that complicate care
Allow for all staff to have time for meetings outside of work (such as regional or national conferences)
Talk with those who have shared a stressful event in the workplace
Modified from Cohn KH, Panasuk DB, Holland JC: Workplace burnout, in: Cohn KH (ed): Better Communication for Better Care: Mastering Physician-Administration Collaboration. Chicago, IL, Health Administration Press, 2005, pp 56-62.