Patient after patient, day after day, and often with no time to eat, let alone to take ten minutes to reflect on how tough cases are affecting them. I work amongst doctors, nurses and pharmacists, and I also grew up with doctors (my mother is a family physician). Watching my mother totally and completely dedicate her life to her chosen profession was pretty educational; I know from living my childhood that “work-life balance” wasn’t a concept that actually existed for physicians or nurses back when she went to medical school (class of '73). I have witnessed first hand the toll its taken on her, and I’ve seen doctors I work with now, everywhere from being on the verge of tears to the other end of the spectrum, on total emotional lockdown, no doubt a difficult and unfortunately learned skill.
About 7 of my 15 years working in the healthcare system in Ontario, have been in oncology. Sometimes people would say to me, isn't it depressing, working in cancer? For me, it has never been depressing, but incredibly hopeful; however, I know that for many of the oncology professionals I know, it can be in fact, really, really hard a lot of the days.
How exactly are you supposed to do your job efficiently, accurately and with as much compassion as you can if you fall apart every time you lose a patient to cancer?
There’s no doubt, being a doctor is emotionally challenging, and oncology physicians have been shown to be at a higher risk for burnout than other health care specialties. Some of the issues they face include serious work overload (large patient volumes, insufficient resources, or poorly managed centres) and a lack of control over their work environment. Women physicians have a tougher time, and working alone and being young are also risk factors. Some of the things that help to buffer against burnout include being married and having children, which likely point to the importance of having healthy, supportive relationships.
Oncologists and oncology nurses are at higher risk for burnout due to the nature and intensity of the clinical challenges they encounter, as well as facing a higher frequency of patient death. End-of-life concerns often require confronting resistance from patients and their families, colleagues, and also their own institutional culture.
Traditionally, medical and popular culture views a patient’s death as the physician failure.
In Ontario, 20 oncologists were interviewed at three hospitals exploring what coping strategies they used to deal with burnout and grief. The results showed they engaged in various rituals, including meeting with families, participating in bereavement rituals in their centre, making a phone call, or sending a condolence card to the family. Specific coping strategies that they reported using included social support, activity-oriented coping (exercise), turning to faith, compartmentalization, and also withdrawing from patients and families. There is no question that these oncologists grieved for patients; however, the ability to demonstrate that grief or find good coping strategies may still be needed . More often than not, a busy day might get in the way, and at least a third of medical, radiation and surgical oncologists surveyed in Canada never participate in these practices .
Oncology nurses of course also suffer from burnout, high levels of job dissatisfaction and distress from their clinical work. Oncology nurses deal with multiple deaths, providing close care for patients, as well as families/caregivers. After a patient death, a nurse is also expected to continue working. However, being able to talk about one’s feelings really does help: one study found many benefits when nurses got together though a support group, including,
· a reduction in end-of-life care stress,
· an increase in self-care, and
· improved patient and team care .
Another study confirmed the validity and benefits of bereavement programs for oncology health care professionals . Some of the types of activates health care professionals can engage in include: attending funerals, holding alternative rituals, calling families, posting photographs and/or sending cards. Staff can take turns each month leading the signing of the sympathy cards, enabling all to personally sign their names and express condolences. These programs tend to garner positive feedback from participants as well as from patients’ families.
How can you tell if you have burnout?
In studies with oncology professionals, burnout syndrome was described by three main dimensions (also called Maslach's dimensions): emotional exhaustion (EE), depersonalization (DP) and low personal accomplishment (PS) . Maslach describes components of these further as:
· Exhaustion: Feeling overextended, both emotionally and physically.
· Cynicism: Taking a cold, cynical attitude toward responsibilities.
· Ineffectiveness: When people feel ineffective, they feel a growing sense of inadequacy.
Its also important to note that if a clinician has burnout, its not that the person is necessarily the problem, but likely it could be because of the social work environment they are in. Maybe they would like to engage in more productive self-care strategies, but they are not in an environment that is supportive.
So, beyond ‘coping’ what exactly is self-care within the context of a cancer care provider?
“Self-care is a spectrum of knowledge, skills, and attitudes including self-reflection and self-awareness, identification and prevention of burnout, appropriate professional boundaries, and grief and bereavement.” 
Unfortunately, there aren’t any courses on self-care or wellness management in our medical or graduate schools.
There are many ways to live a healthy, well-balanced life, including recognizing our inner lives, families, work, community, and spirituality. A widely available tool called the Wellness Wheel refers to 6 types of wellness – physical, intellectual, emotional, spiritual, social and occupational – and allows individuals to reflect on current life balance and self-care. Health care providers can use the Wellness Wheel to improve job satisfaction and overall well being, reducing the likelihood of stress and burnout (you can click the image below for more detailed information).
· prioritizing close relationships such as those with family;
· ensuring adequate sleep,
· regular exercise,
· time for vacations;
· fostering recreational activities and hobbies;
· practicing mindfulness and meditation;
· and pursuing spiritual development.
If you are an oncology care provider and you are struggling to incorporate these types of self-care activities in your life, get yourself to a therapist or seek support from your colleagues. These are skills that everyone can learn, and have had proven benefits for a lot of years. In fact, you may be practicing some of these skills and not even knowing it.
The bottom line is, oncology care professionals are all people too.
Doctors and nurses, pharmacists, social workers, care navigators are all also deeply affected by the nature of the work in cancer care. The system is perpetually stressed, and that isn’t changing anytime soon. All you can do is make sure you set yourself up for success – you’ve got a tough job. Getting support for it is a no-brainer, whether it’s within your own cancer centre, your religious/faith community, your social community or with a professional therapist.
1. Kovács, M. K. (2010). Is emotional dissonance more prevalent in oncology care? Emotion work, burnout and coping. Psycho-Oncology, 19(8), 855-862.
2. Granek, L. K. (2013). Oncologists’ Protocol and Coping Strategies in Dealing with Patient Loss. Death Studies, 37(10), 937-952.
3. Chau, N. G., Zimmermann, C., Ma, C., Taback, N., & Krzyzanowska, M. K. (2009). Bereavement Practices of Physicians in Oncology and Palliative Care. Archives Of Internal Medicine, 169(10), 963-971.
4. Wittenberg-Lyles, E., Goldsmith, J., & Reno, J. (2014). Perceived Benefits and Challenges of an Oncology Nurse Support Group. Clinical Journal Of Oncology Nursing, 18E71-E76. doi:10.1188/14.CJON.E71-E76
5. Marshall, G. (2007). Bringing a bereavement program back to life. Oncology Nursing Forum, 34(2), 506.
6. Trufelli, D., Bensi, C., Garcia, J., Narahara, J., Abrao, M., Diniz, R., & ... Del Giglio, A. (2008). Burnout in cancer professionals: a systematic review and meta-analysis. European Journal Of Cancer Care, 17(6), 524-531. doi:10.1111/j.1365-2354.2008.00927.
7. Richards, K. C., Campenni, C. E., & Muse-Burke, J. L. (2010). Self-care and Well-being in Mental Health Professionals: The Mediating Effects of Self- awareness and Mindfulness. Journal Of Mental Health Counseling, 32(3), 247-264.