Using a detailed questionnaire-based approach, Dr. Kash and colleagues have provided a comprehensive investigation of the extent of poor mental health among staff working in the field of oncology, as well as associated risk factors. A field that lends itself to such study, oncology is widely viewed as an inherently stressful specialty. Working with patients who have life-threatening illnesses is thought to expose staff to suffering and tragedy on a daily basis. At the same time, the conflict between the curative goals of cancer medicine and the reality that many cancer patients will not respond to treatment in the long term can lead to feelings of personal failure.
Feeling inadequately equipped to deal with the emotional response of patients and their families can be a further source of stress among staff, whose work may also force them to face their own mortality, as well as that of family and friends. Having to deal with these specific sources of stress, along with the generic difficulties of health-care work, has led to a perception that oncology staff are at greater risk of developing poor mental health.
Burnout by Stress
Kash et al have found some evidence to confirm this view, with oncologists, house officers, and nurses as a group reporting higher burnout scores than a control sample of health professionals. Specifically, their study showed that these three groups were more emotionally exhausted by their work and demonstrated a more impersonal, unfeeling response toward patients.
There are, however, few studies that have compared specialists systematically using standardized instruments. Moreover, research comparing oncologists with other specialists in the United Kingdom has not found any differences in levels of burnout or psychiatric morbidity.[1,2] Why might this be? The answer seems to lie in factors that are actually generic to the role of doctor. In fact, oncologists report work overload, poor management and resourcing, and dealing with patient suffering to be predominant sources of stress.
Furthermore, compared to other specialist groups with clinical responsibility for patients, oncologists do not report higher stress from dealing with patient suffering and do not, therefore, appear to experience uniquely high levels of stress from this aspect of work. This finding—based on a systematic evaluation—contradicts the vast anecdotal literature that describes the particularly difficult time oncologists have in working with their patients.[4-8]
The Gender Issue
Kash et al found that women working in oncology had higher levels of burnout in the form of reduced personal accomplishment than men, and also had a greater number of symptoms of demoralization. Other studies of poor mental health among doctors have also found a higher prevalence among women,[9-14] but the difference has not always been found among nurses or doctors.
In an exploration of gender differences among physicians, the higher rate of mental health problems among women doctors was not explained by gender differences in any work factors, such as hours of work, perceived workload, role ambiguity or conflict, autonomy, social support, or amount of patient contact. It appears that other work factors that were not assessed in the study, such as aspects of the culture of medicine, may impact more negatively on women doctors than men.
Importance of Job Satisfaction
The high rate of personal accomplishment reported by oncologists in this study indicates that they feel they are positively influencing their patients’ lives and that their work achievements are worthwhile. Oncologists derive high levels of satisfaction from their work overall, particularly from working with patients and relatives, from their professional status and associated colleague respect, and from the intellectual stimulation that their role provides. Importantly, job satisfaction has been shown to protect consultants’ mental health from the harmful effects of job stress.
Research based on Karasek’s demand-control model of job stress shows that for individuals involved in jobs with high demands, such as medicine, the amount of discretion a person has over his/her work is an important determinant of mental health. Autonomy has been shown to be an important source of job satisfaction for senior doctors, including oncologists. It appears that oncologists may be able to tolerate the demands of their job as long as they derive satisfaction from its performance. Furthermore, it is vital to the mental health of these doctors that changes to their role do not erode these sources of satisfaction.
Training in Communication and Management Skills
As Kash et al point out, medical care is becoming more complex in terms of the technology involved and patient demands. It is important that staff possess the skills to meet the demands of their developing role. For the most part, oncologists appear to believe that their training in disease management is sufficient for the performance of their role, with 89% feeling sufficiently trained in both treatment of disease and symptom control.
Far fewer oncologists (56%) considered themselves to have received sufficient training in another important clinical skill: communication. Only 20% felt sufficiently well trained in management skills. The increasing emphasis on patient-centered care requires the integration of more traditional disease-management skills with more “people-oriented” skills, including communication and management.
It appears that the adequacy of physician training may also have an impact on mental health. Specialists who felt insufficiently trained in these skills were at increased risk of burnout, while doctors and nurses with higher burnout scores were shown to communicate less effectively with patients. It is essential that delivery of training in these two skill areas be integral to undergraduate and postgraduate training, both for the oncologist’s clinical performance and for the protection of his/her mental health.
Ways of Coping
Looking at the factors that Kash et al found predicted poor mental health in oncology staff, one that consistently arose was the use of cigarettes, alcohol, or medication as a method of relaxing. Among senior doctors in the United Kingdom, including oncologists, the use of drugs and alcohol to relax has been found to be associated with psychiatric morbidity. In contrast, lower psychiatric morbidity occurred when this group made efforts to maintain a healthy lifestyle while experiencing stress, through involvement in hobbies and exercise, healthy eating, and not working long hours.
Workloads in oncology can make it difficult to achieve a healthy lifestyle, however, and it may be easier for staff to reach for the quick fix of drugs and alcohol. If, as these studies suggest, the ways in which staff cope with the stresses of their role can influence mental health, there are implications for an occupational culture that can make maintaining a healthy lifestyle difficult.
Life Outside Work
Sources of stress do not only occur in the work environment; they occur in other domains of life. However, very few studies of physicians have examined sources of stress outside work. One recent study of doctors has elegantly demonstrated that psychiatric morbidity is related both to work stress and to life events or difficulties outside work.
The mental health of staff providing care to cancer patients is an important subject for study, which has implications—beyond the suffering of staff and their families—for standards of patient care and for the retention of staff in the professions involved. The study by Kash et al highlights four important factors that provide a basis for reducing poor mental health among these staff members: first, that negative work events are a causal factor for poor mental health; second, that young and female health professionals are particularly vulnerable groups; third, that the ways in which staff cope with the stress of their role are related to their mental health; and fourth, that protecting sources of job satisfaction is vital for staff to continue to tolerate the demands of working in this challenging field without harm to their mental health.
As with almost all research in this area, the study design is cross-sectional. Thus, the direction of relationships identified here requires confirmation in further studies using a longitudinal approach.
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