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© 2003 American Society for Clinical Oncology
When Your Favorite Patient Relapses: Physician Grief and Well-Being in the Practice of OncologyFrom the Department of Oncology, Mayo Clinic, Rochester, MN; and Department of Medicine and Biological Chemistry, University of California at Irvine, Irvine, CA. Address reprint requests to Frank L Meyskens, JR, MD, Comprehensive Cancer Center, University of California at Irvine, 101 The City Drive South, Rte 81, Bldg 23, Orange, CA 92868-3201; email: flmeyske{at}uci.edu. IT’S GOOD Friday and the end of a long week. I smile to see one of my favorite patients at the end of the day’s schedule. All of us have those patients who touch us more deeply than others. My patient, Mr X, is a 50-year-old white male who was diagnosed with localized leiomyosarcoma of his right thigh in 1996. I had taken great satisfaction in his outcome. He had returned to full time work and a normal lifestyle; he was a silver lining, indeed, amid many other patients of mine who had not fared so well. At his 5-year follow-up visit, a routine computed tomography scan demonstrated pleural disease on the right side. Given the focal recurrence after a long disease-free interval, he underwent removal of resectable disease followed by additional chemotherapy. Follow-up computed tomography scan and positron emission tomography scan were negative at the completion of therapy. I hoped in my heart that he was free of disease. I glanced at his scan on my way to his room, my eyes in disbelief quickly traveling to verify the name in the corner. The report confirmed what I had seen, "new pleural mass since most recent evaluation, extensive pleural disease." The emotion and introspection triggered by that encounter acted as an earthquake that reverberated through the Easter weekend. The poem that follows is an account of my struggle. Tidal Wave So many have passed this way before, So many have passed this way So many have passed, Where in the lexicon of learning So many have passed this way, By Frank L. Meyskens, MD THE ISSUES: OCEAN RISING BEHIND THE DOOR The above experience raises issues and emotions that are not unique to its author. Grief, futility, exhaustion, guilt, and the existential aspects of being a physician are realities of medical practice that must be confronted by all oncologists. As the above verses express, we may feel powerless and overwhelmed by tidal waves of bad news, treatment failures, patient suffering, medical futility, and death, which are all part of the everyday practice of oncology. Dr Meyskens’ poem provides an opportunity for reflection. PHYSICIAN GRIEF: SO MANY HAVE PASSED THIS WAY BEFORE Although much has been written about the grieving process of patients and their families, little is known about physician grief.1–4 As a professional caregiver, the physician is expected to be an honest, compassionate, and knowledgeable guide who is able to advise and comfort patients and families in their most desperate hours. But physicians are no less human than others. In fact, many have been drawn to medicine through their sensitivities to the needs and the suffering of others. Physicians forge close relationships with many patients with whom they have shared significant tears, trials, and triumphs of diagnosis and treatment. Unfortunately, although physicians often successfully execute their duty of support to patients and families, they commonly have little time to process their own sorrow about their patients’ death and suffering.1 Instead, more often than not, the extra time spent being a compassionate provider to the last patient has left them 30 minutes late for another needy patient. Thus, they shelve their unresolved emotions from the last encounter in an effort to serve the next patient. But these rain checks have a tendency to stack up. If the grief is not appropriately resolved, it overflows. When there is no more room to store additional grief, we lose the ability to be compassionate and invested with patients. This distress from work can then spill over into our personal life. One response is to become callous, technical, and distant. Although some degree of detachment is healthy and even necessary to maintain perspective, being too detached may render us ineffective healers. The depersonalization that results can slowly exhaust our compassion and lead to a lack of engagement with patients and eventually to burnout. PHYSICIAN LIMITATIONS: WANTING MY MIRACLE The hopes, expectations, and denial of certain patients and families can also be a heavy cross to bear. Physicians make significant personal sacrifices for their patients, often sacrificing personal time, sleep, hobbies, and even family life to meet the needs of their patients. The sacrificial nature of being a physician is expressed in Dr Meyskens’ poem in the cry, "summon me". Yet despite the altruism of oncologists, the progress of science, and the requests of our patients, miracles are few and far between. Physicians must be mindful and calculated in their sacrifices. Our resources and reserve are ultimately limited; thus, unrestricted sacrifice without adequate opportunities to recharge eventually leads to personal depletion and loss of effectiveness. PHYSICIAN GUILT: THOSE ENTRUSTED TO ME Failure to accept limitations leads to physician guilt. Oncologists’ sense of commitment and obligation to their patients can lead them to feel somehow personally responsible for their inability to produce miracles. After all, these patients are entrusted to us, and we feel the weight of that responsibility. Patient appeals, such as "There must be something else you can do," can strengthen the miracle worker paradigm and can lead physicians to pursue treatments and interventions they suspect are unwarranted. Feelings of failure and inadequacy may spur additional attempts at salvage therapy, rather than helping patients transition to a palliative approach. Medical mistakes also can cause significant physician guilt and are often borne in silence.3–6 But doctors are not deities, and a misguided sense of duty is a foundation for unsound medical decisions and ineffective oncologic care. Despite our best intentions, we often have little ability to reverse the course of malignant diseases. Accepting this fact allows us to pursue the meaningful work of helping patients come to terms with their illness and to make decisions about how to spend the remainder of their lives. In Dr Meyskens’ poem, the oncologist’s recognition that many of his patients are "needing solace and nothing more" is a critical reframing of his role from savior to shepherd. It is in this role that he can guide the patient’s struggle to accept his illness and relieve suffering. PHYSICIAN EXHAUSTION: THE SEA FORESTALLED The recurring analogy of the physician acting as a dike holding back an overwhelming sea is a powerful image that resonates with oncologists. Studies on distress and burnout in physicians indicate that the most compassionate doctors may be the most vulnerable to physician burnout,7 a syndrome of emotional exhaustion, depersonalization, and a low sense of personal accomplishment that leads to decreased effectiveness at work.8 Burnout primarily affects individuals whose profession involves an intense involvement with people. It has been found in a wide range of practicing physicians from interns to department chairs.9–11 A number of studies indicate that burnout adversely affects the medical care physicians deliver.5,9,10 Oncologists may be particularly vulnerable to burnout because of the emotional nature of caring for patients with terminal illness, with studies reporting that 25% to 50% of oncologists experience burnout.12–14 Oncologists also often receive little training regarding how to communicate bad news to patients or how to deal with patients’ emotional reactions.15 This lack of training on how to advise, empathize with, and counsel patients may lead to additional distress for oncologists.12 New avenues to improve this training for oncology fellows have been developed.16,17 Avoidance is one method of dealing with this lack of training on delivering bad news. An oncologist presenting a blithely optimistic impression to a patient with metastatic disease who has a good response to treatment is one example. Ultimately, avoiding discussing the reality of disease behavior with patients robs them of opportunities to reflect on values and make decisions about how to live the rest of their lives.18 Physician burnout is a complex phenomenon that can be the net result of a number of personal and professional factors. On a professional level, having inadequate training in dealing with dying patients, inadequate control over practice setting, inadequate support staff, and a lack of open and supportive relationships with colleagues all seem to contribute to burnout.12 On a personal level, problems in relationships, inadequate personal time, and the absence of identifying meaning in the work experience may also contribute.9,14,19–21 Additionally, the tension between personal and professional responsibilities can be an even more significant contributor to burnout than the job or personal characteristics themselves.22,23 Oncologists who feel they are unable to be a good spouse and/or an involved parent because of the demands of their work are at high risk for burnout.22,23 EXISTENTIAL ASPECTS OF BEING A PHYSICIAN: OH GOD, WHAT DO YOU DEMAND OF ME? The practice of medicine can certainly be a spiritual endeavor. Indeed, patients do entrust their lives to us, and we routinely make decisions that can affect the length and quality of their life. Oncologists are confronted daily with transcendence, suffering, uncertainty, and mortality. These forces occasionally create moments of epiphany that help us redefine our values and purpose. More often, they may make life seem meaningless and bewildering. Mistakenly, physicians often feel alone with these challenges and struggle in silence and isolation. This solitude limits opportunities to connect with colleagues and gain insight from the experience of others. Perhaps it is no coincidence that Dr Meysken’s experience occurred on Good Friday and that he penned his poem over the ensuing Easter weekend. In the Christian calendar, this weekend symbolizes the sacrifice of Christ and the hope of life after death. Spiritual practice and belief in a higher power can be a source of light and hope in the midst of darkness for patients and physicians alike and provide one context from which to deal with the experience of patients’ death and suffering.9,20,24 ACCEPTANCE AND PHYSICIAN WELL-BEING: TAUNT ME NO MORE Oncologists must recognize the above issues if they are to avoid burnout and achieve renewal and well-being. A number of specific suggestions can be helpful in preventing burnout. Developing approaches to delivering bad news and dealing with emotional responses to bad news can help minimize the stress precipitated by these tasks frequent to oncologists.12 Allowing adequate personal time to grieve our own losses can bring healing that preserves compassion and prevents struggles at work from spilling over into personal relationships.1,2 Limiting workload, designing flexibility in scheduling, and developing coverage systems with colleagues can minimize tension between personal and professional life and help immunize against burnout.23,25–27 Identifying and reflecting on the existential aspects of being a physician is an opportunity for personal growth. Regular meetings with colleagues to discuss grief, mistakes, suffering, and the personal challenges and rewards of medicine can strengthen self-awareness and help physicians realize that they are not alone.20,28,29 A variety of formats that foster personal and physician reflection, generally built on confidentiality, active listening, and limitations on criticism or giving advice, are effective.28 These meetings are an opportunity not only to share struggles, but also to promote a sense of being connected, to reaffirm professional values, and to enrich practice. Religious or spiritual practices can be equally important as a source of renewal for many physicians.9,20,24 Recovery from burnout is possible, with increasing evidence indicating that physicians can actively promote their own well-being.20,24,26,30 Placing limits on work, nurturing and protecting personal relationships, pursuing self-care activities (such as exercise and hobbies), engaging in religious and spiritual practices, and developing a life philosophy that promotes balance between the personal and professional lives are characteristics of healthy physicians.20,24 A time of introspection to reflect on values can be an important first step to identifying priorities and incorporating them into our lives.30 Comprehensive reviews of physician well-being have been published.26,27 CONCLUSION All physicians confront the "tidal wave" at some point in their practice. Weathering this storm is no trivial task. We face the onslaught of grief, exhaustion, guilt, existentialism, and burnout. We question our strength, our values, our motivation, and our reserve. Ultimately, as Dr. Meyskens demonstrates in his poem, recognizing and accepting our abilities and limitations brings healing and an opportunity for personal growth. Developing a personal strategy to promote well-being is critical. The realization that we stand with a host of others who have "passed this way before" allows opportunities to develop a sense of connectedness with colleagues that can be both healing and rejuvenating. Recognizing these challenges and proactively promoting our own wellness can help us survive the tidal wave—to "stand down and let it pass" so it will "taunt us no more." REFERENCES
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2. Bruce CA: The grief process for patient, family, and physician. J Am Osteopath Assoc 102:S28–S32, 2002 3. Christensen JF, Levinson W, Dunn PM: The heart of darkness: The impact of perceived mistakes on physicians. J Gen Intern Med 7:424–431, 1992[Medline] 4. Newman MC: The emotional impact of mistakes on family physicians. Arch Fam Med 5:71–75, 1996[Abstract]
5. Blendon RJ, DesRoches CM, Brodie M, et al: Views of practicing physicians and the public on medical errors. N Engl J Med 347:1933–1940, 2002 6. Charles SC: Coping with a medical malpractice suit. West J Med 174:55–58, 2001[CrossRef][Medline] 7. Firth-Cozens J: Emotional distress in junior house officers. BMJ 295:533–536, 1987[Medline] 8. Maslach C, Jackson S, Leiter M: Maslach Burnout Inventory Manual (ed 3). Palo Alto, CA, Consulting Psychologists Press, 1996
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10. Bellini LM, Baime M, Shea JA: Variation of mood and empathy during internship. JAMA 287:3143–3146, 2002 11. Gabbe SG, Melville J, Mandel L, et al: Burnout in chairs of obstetrics and gynecology: Diagnosis, treatment, and prevention. Am J Obstet Gynecol 186:601–612, 2002[CrossRef][Medline] 12. Ramirez AJ, Graham J, Richards MA, et al: Burnout and psychiatric disorder among cancer clinicians. Br J Cancer 71:1263–1269, 1995[Medline] 13. Whippen DA, Canellos GP: Burnout syndrome in the practice of oncology: results of a random survey of 1,000 oncologists. J Clin Oncol 9:1916–1920, 1991[Abstract] 14. Kash KM, Holland JC, Breitbart W, et al: Stress and burnout in oncology. Oncology (Huntingt) 14:1621–1633;discussion 1633–1634, 1636–1637, 2000[Medline] 15. Gilewski T: The art of medicine: Teaching oncology fellows about the end of life. Crit Rev Oncol Hematol 40:105–113, 2001[Medline] 16. Back AL: Contact information. www.depts.washington.edu/oncotalk/contacts.html 17. Lee S, Back AL, Block SD, et al: Enhancing physician-patient communication. Hematology (Am Soc Hematolo Educ Program) 464–483, 2002
18. Block SD: Perspectives on care at the close of life: Psychological considerations, growth, and transcendence at the end of life—The art of the possible. JAMA 285:2898–2905, 2001 19. McMurray JE, Linzer M, Konrad TR, et al: The work lives of women physicians results from the physician work life study: The SGIM Career Satisfaction Study Group. J Gen Intern Med 15:372–380, 2000[Medline] 20. Quill TE, Williamson PR: Healthy approaches to physician stress. Arch Intern Med 150:1857–1861, 1990[Abstract] 21. Gabbard GO, Menninger RW: The psychology of postponement in the medical marriage. JAMA 261:2378–2381, 1989[Abstract] 22. Linzer M, Visser MR, Oort FJ, et al: Predicting and preventing physician burnout: Results from the United States and the Netherlands. Am J Med 111:170–175, 2001[CrossRef][Medline] 23. Geurts S, Rutte C, Peeters M: Antecedents and consequences of work-home interference among medical residents. Soc Sci Med 48:1135–1148, 1999[CrossRef][Medline] 24. Weiner EL, Swain GR, Wolf B, et al: A qualitative study of physicians’ own wellness-promotion practices. West J Med 174:19–23, 2001[CrossRef][Medline] 25. Linzer M, Konrad TR, Douglas J, et al: Managed care, time pressure, and physician job satisfaction: Results from the physician worklife study. J Gen Intern Med 15:441–450, 2000[CrossRef][Medline] 26. Shanafelt T, Sloan J, Habermann T: The well-being of physicians. Am J Med (in press)
27. Spickard A Jr, Gabbe SG, Christensen JF: Mid-career burnout in generalist and specialist physicians. JAMA 288:1447–1450, 2002 28. Rabow MW, McPhee SJ: Doctoring to heal: Fostering well-being among physicians through personal reflection. West J Med 174:66–69, 2001[CrossRef][Medline] 29. Novack DH, Suchman AL, Clark W, et al: Calibrating the physician: Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA 278:502–509, 1997[Abstract] 30. Clever LH: A checklist for making good choices in trying or tranquil times. West J Med 174:41–43, 2001[CrossRef][Medline] Submitted July 5, 2002; accepted April 17, 2003. This article has been cited by other articles:
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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