Surviving the Stresses of Clinical Oncology by Improving Communication

March 1, 2004

Oncologists grapple with an element of psychological stress that relatesto the suffering their patients experience. Although this stress maynot be unique to oncology, it is profound. When these stresses becomeoverwhelming, they lead to physician burnout. It is important to understandwhat makes an oncologist feel successful, what coping strategieshelp combat burnout, and what adds to the process of renewal. Thedoctor-patient relationship plays an important role for many oncologistsin this regard, and communication skills are increasingly recognizedfor their importance in this arena. We outline several clinical scenariosthat pose particular challenges to oncologists. These include breakingbad news and the patient’s response to hearing bad news, transitions incare and offering end-of-life care, participation in investigational studies,error disclosure, complementary and alternative medicine, spirituality,family discussions, and cross-cultural issues. By highlighting therelevant psychosocial issues, we offer insight into, and tools for, anenriched dialogue between patient and oncologist. The doctor-patientrelationship can be viewed as the ultimate buffer for dealing with thehassles encountered in clinical oncology.

ABSTRACT: Oncologists grapple with an element of psychological stress that relatesto the suffering their patients experience. Although this stress maynot be unique to oncology, it is profound. When these stresses becomeoverwhelming, they lead to physician burnout. It is important to understandwhat makes an oncologist feel successful, what coping strategieshelp combat burnout, and what adds to the process of renewal. Thedoctor-patient relationship plays an important role for many oncologistsin this regard, and communication skills are increasingly recognizedfor their importance in this arena. We outline several clinical scenariosthat pose particular challenges to oncologists. These include breakingbad news and the patient’s response to hearing bad news, transitions incare and offering end-of-life care, participation in investigational studies,error disclosure, complementary and alternative medicine, spirituality,family discussions, and cross-cultural issues. By highlighting therelevant psychosocial issues, we offer insight into, and tools for, anenriched dialogue between patient and oncologist. The doctor-patientrelationship can be viewed as the ultimate buffer for dealing with thehassles encountered in clinical oncology.

Oncologists face a multitude ofstresses in their daily clinicalwork. Like most physicianstoday, they are overburdened withpaperwork, phone calls, and the stressof having to see too many patients intoo little time. In addition to this aspectof clinical medicine in the currenthealth-care climate, oncologistsgrapple with an element of psychologicalstress that relates to the sufferingtheir patients experience. Althoughthis stress may not be unique to oncology,it is profound.[1]Each patient, from the moment adiagnosis of cancer is made (and ofteneven before then), is in crisis.[2,3]Each transition in care (recurrence ofdisease, progression of disease, failureto respond to treatment, and ofteninevitable end-of-life transitions) representsa new crisis.[4] The oncologistis witness to frequent and repeatedepisodes of suffering by the patientand the family,[1] and treats not onlythe biologic disease, but also the highlevels of distress and pain that unfortunatelyaccompany cancer. Many relationshipswith patients end in death.Impact of Stresson the PhysicianThese stresses demand time, energy,and emotion, and oncologistsanswer this call. Physicians have beennoted to represent a rather overachievinggroup, willing to place high demandson themselves with a tendencyto work long hours, have perpetuallyhigher performance expectations, andleave themselves little time for leisure.Physicians are not taught to slow downand are not encouraged to show signsof fatigue or grief. Physicians can beleft feeling guilty about not havingspent more time with their patients andthe patient's families. Their sympathyfor the patients' plight is great, andguilt over feelings of failure when theyare unable to reverse this plight ishigh.[5] In addition, these feelingsmay be particularly painful when thephysician either identifies with thepatient personally (ie, similar age) oris reminded of a family member whomay have died.Personal factors add to the professionaland emotional stress of oncology.Many physicians feel guilt over time not spent with their own family.[6] This can be intensified in oncology:How does your child's soccergame compete with your patient'sdeath? Who wins and who loses? Often,it is the oncologist who furthersacrifices personal time in order tomeet the professional demands on hisor her time.Burnout
These stresses can become overwhelming.[7] The term "burnout" hasbeen defined as occurring when workand/or other demands exceed the abilityto cope, resulting in psychologicaldistress and/or physical symptoms. Across-sectional study of American Societyof Clinical Oncology (ASCO)members found 51% acknowledgedfeelings of burnout.[8] Maslach identifiedthree components of burnout:(1) emotional exhaustion, from all thehassles and stresses encountered; (2) depersonalization,ie, a loss of empathyand feeling for patients and families;and (3) diminished sense of personalachievement and performance.[9]These three components represent threeimportant areas of function for physicians:maintaining emotional wellbeing,relatedness to others, and asense of professional accomplishment.Most oncologists experience highlevels of stress that can lead to emotionalexhaustion. Depersonalization,while acting to diminish emotionaldistress, can become maladaptive.(The sense of accomplishment is diminishedwhen one is no longer opento hearing patients' tragedies and triumphs,or no longer able to listen attentivelyand communicate in a supportiveand comforting way.) Maintainingthat sense of personal accomplishmentis important to offset thestresses that might otherwise lead toemotional exhaustion and depersonalization.The majority of oncologistsfeel that their field is challenging butrewarding.[8,10,11] How then dooncologists survive?Survival KitHolland has developed a "survivalkit" for oncologists (personal communication,J.C. Holland, 2002). Shestresses the importance of maintaininghumor, as illustrated by the longrunning1970s television series,M*A8S*H. Gallows humor has longbeen used by physicians to help relievethe tension of frequent encounters withdeath.She also stresses the importance oftime away from work. She recommendsprotecting that time as muchas time with patients, and honoringdates and schedules for leisure time asemphatically as work dates and schedules.Diet and exercise are equallyimportant for physicians and for patients.In addition, the importance ofmonitoring ourselves as well as ourcolleagues for signs of burnout is critical.Early signs of burnout includeemotional fatigue, loss of pleasure andenthusiasm for work, being easily irritatedand annoyed with others atwork and at home, or having physicalsymptoms that are found to have nophysical origin (headache, arthralgias,anorexia or overeating, insomnia) andare likely stress related. Lastly, it isimportant to watch for dependence onalcohol or prescription drugs, whichare occupational hazards for overstressedphysicians.Of course, many of these issues arenot unique to oncology, and there isa growing literature on physiciancoping. [1,12-17]Communication
These global factors of stress existin medicine in general, and in clinicaloncology in particular. Some recurrentthemes in clinical oncology are particularlystressful. It has been postulatedthat another way to reduce stressin clinical oncology is to improvecommunication.[7]A study by Ramirez and colleaguesin the United Kingdom found thatoncologists who expressed an inabilityto communicate with patients hadgreater stress and more symptoms ofburnout.[11] A subsequent study confirmedthat feeling insufficientlytrained in communication skills wasassociated with less reported job satisfactionfrom relationships with patients,relatives, and staff.[18] This studyconcluded that improved communicationcould increase job satisfaction.Encounters and conversations thatoccur between patients and theironcologists require particular skill andattention to the patient's emotionalneeds.[19] The basic tools with whichto initiate and conduct these discussionsare rarely taught; yet, it is thesevery communication skills that cementthe doctor-patient relationship and diminishstress for both.Clinical ScenariosSeveral difficult discussions arepresented below, highlighting psychosocialissues from both the patient'sand physician's perspective, with thegoal of elucidating potential obstaclesto communication and offering insightinto ways to approach them.Breaking Bad News
There is a growing literature ontechniques for the delivery of badnews.[20-34] The Buckman and Bailemnemonic "SPIKES" is perhaps mostcommonly used.[35] In this model, theacronym SPIKES stands for set-up,perception, invitation, knowledge,emotions and empathy, strategy andsummary.Set-up includes such details as turningoff one's pager, having tissuesavailable, sitting down, and makingeye contact. Perception refers to theimportance of asking patients for theirperception of the illness prior to continuingthe dialogue. Invitation refersto asking patients how much they wantto know, and getting permission to disclosethe bad news. Only after thesesteps have been taken should the informationor knowledge be imparted.While it is important to empathize,it is equally important to resist the urgeto jump in immediately in an attemptto "rescue" the patient. Rather, a remarksuch as, "This must be awful tohear," allows patients to explore andarticulate their emotions. Lastly, theimportance of summarizing andstrategizing serves as reinforcement.Although these steps need not be followedsequentially or by rote, theyoffer a helpful model.The need to break bad news arisesfrequently in clinical oncology,whether discussing a new diagnosis,recurrent disease, progressive disease,or the lack of further chemotherapeuticoptions. Lesley Fallowfield andcolleagues estimate that an oncologistbreaks bad news thousands of timesin his or her career.[36] Each transitionin a patient's care that representsdisease progression requires the deliveryof even further bad news.[4]Patients often respond with questionslike "What does this mean?" or"How long do I have?" One approachto these difficult questions is to resistthe urge to answer immediately, andrather, to validate the importance ofthese questions, and to ask for furtherelucidation on any element that mightbe particularly upsetting. While onepatient may be most scared of pain orsuffering, another may be focused onattending a special event, such as achild's wedding or graduation.I want to answer your questions. ButI want to make sure I understand whatyou're asking. Can you tell me a littlebit more about what you're thinkingright now? This must be very difficult.Eliciting this information serves toinform the physician of these importantdetails, and communicates concernas well as continued commitmentto the patient.[37] Before answering aquestion such as "How long do Ihave?" it is crucial to determine thelevel of information the patient wantsto hear. ("I need to know specificallyhow detailed the information you wantto hear should be.") This prepares boththe patient and the physician for themost sensitive delivery of information.Coping Styles
Patients have a broad range of copingstrategies, which they use to varyingdegrees at different points in theirdisease and with varying levels of success.Some patients withdraw; othersbecome angry. ("How do you thinkI'm feeling, doc?!") Perhaps most difficultof all for the oncologist is thepatient in denial. ("This doesn't meananything, right?") Keeping the lines ofcommunication open can be particularlyimportant in these cases. Responsessuch as: "You seem angry," or "Tell me what this means to you and how you understand it," or "Thismust be very upsetting. Can you bearto tell me what you're thinking?" canhelp patients explore their emotionsand reveal their fears, goals, and expectations.Exploring these issueshelps to elucidate the facts, which inturn facilitates better coping.Transitions in Care
The level of stress (and distress) inpatients is highest at transition pointsin treatment. Questions such as, "Isn'tthere anything more we can do? Whydidn't that last treatment work? It'sreally bad now, isn't it?" reflect thepainful process of understanding anddealing with the information.Here again, the oncologist has anopportunity to review with the patientwhat has happened, what decisions havebeen made, and what outcomes havetranspired. This recounting of thepatient's disease course serves to bringtogether the patient's and the oncologist'sperspectives. Once this sharedground has been reached, there is theopportunity to inquire again into thepatient's fears, goals, and expectations.The physician can then frame the nexttreatment plan in the context of thepatient's goals and wishes-whetherthat may be further treatment, expectantobservation, or supportive care.In the absence of such a conversation,the decision for expectant observation,for instance, can generate intenseanxiety and doubt. "Shouldn'twe be getting more tests? Are you givingup on me?" Questions such asthese should prompt the oncologist toundertake a more detailed discussion,reframed in the context of the patient'sdisease state and goals.End of LifeEnd-of-life care is a field rich in literatureand experience. The initiationof the discussion with the patient issomething oncologists must do routinely,yet often feel uncomfortabledoing.[38] Feelings of failure that thedisease has progressed, as well as discomfortwith the topic of death in general,are obstacles to the initiation ofthe discussion.When is the best time to initiatesuch a discussion? How does one startthe dialogue? Again, eliciting patients'understanding of their illness and theirwishes, and giving them a sense ofcontrol, are good starting strategies. Asin any other transition in care, reviewingthe patient's course (the "narrative")can be a useful tool in initiatingthe conversation.Offering Comfort Care
Three points of contention maypose particular difficulty to the oncologist.One such situation is that of offeringcomfort care. The patient maybe thinking, "I don't want to give up,"and the idea of "no further treatmentoptions" may be frightening to both thepatient and the oncologist. Often, it iseasier to discuss nth-line chemotherapyor phase I trials (that may have exceedinglylittle likelihood of benefit) thanthe alternative of palliative care.[39]However, deferring the conversationrobs both the patient and oncologist ofan important opportunity to lay thefoundation for future discussions.Remembering that word choice canmake an important difference in theseconversations, it is helpful to discussend-of-life care in terms of "comfortcare" rather than "withdrawal of care,"with the emphasis on achieving maximalquality of life and freedom fromdistressing symptoms, especially pain.The obligation of the oncologist is toassure commitment to the patient's careand dignity, as well as the willingnessto discuss the patient's concerns,whether they be personal, physical,emotional, or related to family issues.Advance Directives
Second, discussing advance directives,code status, or do not resuscitate(DNR) orders can be particularlydifficult. Once again, when framingthe conversation in the context of understandingthe patient's goals andwishes, this discussion becomes easier.For example:I think it's important that I take thetime now, while you're doing welland this is not an issue, to ask whatyou would want done if there evercame a time when you could not tellus yourself... That is, right now youare stable, and doing well. And I haveno reason to think this might changeany time soon. If, however, there evercame a time when something didhappen, have you thought about whatyou would want done?... That is, ifyou were to suffer a catastrophicevent, and your heart or breathingwere to stop, have you given thoughtto what you would want done in thissituation?... That is, would you wantus to use machines to artificiallyresuscitate you?... Some people feelthat in that situation, they wouldrather go in peace than to have somuch done to them, when therewould be so little likelihood that itwould offer benefit for them. That is,we know that when patients havecancer and require those machines,the likelihood that they are able toever leave the hospital is exceptionallyslim. Have you ever giventhought to this matter?... Havingheard what I've said, can you tell mewhat your thoughts are now?Reassurances that everything shortof artificial resuscitation would stillbe done can be quite helpful. ("Wewould still do everything short of artificialresuscitation, but if we knewyour wishes were to prioritize dignityand comfort, we could see to that.")When the patient's wishes havebeen elicited, the ability to frame thisdiscussion in the context of goals andexpectations is powerful and effective.That is, future treatment decisionsbecome grounded in the contextof the patient's stated goals, ratherthan the physician's assumptions. Althoughsome oncologists fear disabusingtheir patients of hope, theconversation may actually reestablishtrust and faith by reassuring that painand distress will be treated aggressively.[38,40] This open communicationmay free the patient from undueanxiety and fear, and allow emotionsto remain more positive and hopeful.Physician-Assisted Suicide
Third, requests for physicianassistedsuicide, while infrequent, canbe difficult to handle. Regardless ofthe physician's personal or professionalviews on this topic, or the lawin the state of practice, this request canserve as an important prompt for a reneweddialogue between the patientand physician. Such questions as "Youseem to be thinking about death. Can you tell me what you've been thinking?"may open the door for communication.Regardless of the outcome ofthe discussion, the willingness to havethe discussion, and the opportunity togain insight into the patient's perspectiveand fears, sends an important messageof concern to the patient. Manypatients are relieved to be able to expressthese thoughts, and the conversationcan highlight the need for anadditional intervention to reduce atroublesome symptom or clarify anunderappreciated conflict or concern.Investigational StudiesOncologists frequently enroll patientsin investigational studies. Froman oncologist's perspective, the ideaof what to explain, and in what levelof detail, is a daily dilemma.[39] Thedescription of studies must be in languagethat is easily understood anddevoid of technical terms.[19]Patients may respond with "I don'twant to be a guinea pig" or "How experimentalis this?" This representsanother opportunity to "review thepatient's narrative"-that is, to discussthe treatment history and review howor why an investigational study mightfit into the patient's goals. For the patientwho has already reached thatpoint, or may be harboring the misconceptionthat an investigational(phase I) trial will offer successfultreatment for the disease, further discussionmight still be necessary. Indeed,a recent study showed that patientshave a more optimistic view ofphase I and II protocols than do theironcologists.[39] A line as simple as"Tell me what you understand aboutthis study" or "Tell me what's beenexplained to you about this so far" mayhelp to correct any misunderstandings.In a study of why patients acceptedtreatment through investigative protocols,Penman and colleagues identifiedthree factors: (1) "I thought it offeredsome hope," (2) "I trusted the doctor,"and (3) "I was afraid of what wouldhappen if I didn't accept it."[41] Patientsfelt the informed consent discussionwas far less important than howthe doctor presented the protocol andwhether they were spoken to in a compassionateway.As a simple rule of practice, someclinical investigators make sure thathospice care is discussed as an alternativefor all patients consideringphase I trials in the metastatic setting.Some informed consent forms includemention of this alternative. This is oneway of ensuring that discussions haveincluded all options.Error DisclosureMedical errors occur more often thanpreviously recognized and far morecommonly than is reported to patients.[42] Disclosure of errors traditionallyhas not been a part of medical education,although this is changing. Admittingwhen a mistake has been madecan be difficult, emotional, and timeconsuming.Robert Buckman has developedan approach to this situation.[43]He advises full disclosure, which includesan explanation of how the erroroccurred, as well as the steps taken toprevent it from happening again in thefuture. He suggests that error disclosureis "breaking bad news without an invitation,"since bad news must be deliveredregardless of whether the patientor family wishes to hear it.[43]A warning remark, however, canserve to preface the discussion: "I havesome serious news that I need to discusswith you." This approach mayanswer the patient's or family's question:"How could this have happened?"Buckman advises the physicianto accept full responsibility forthe error-"as your physician, I am ultimatelyresponsible for every aspectof your care, and I take full responsibilityfor this situation." Efforts to keepthe patient and family informed prospectivelyand in a timely manner keepthe lines of communication open insuch a difficult situation.Complementary or Alternative MedicineIt is estimated that at least 50% ofpatients use some form of alternativeor complementary medicine.[44]Some physicians shrug it off, ignore it,or universally advise against such alternatives.Many patients firmly believe inthe benevolence of vitamins, supplements,and herbs.[45] "They can't hurt me, right?" The lack of evidence to suggestbenefit and growing concerns overrisk make the recommendation of somealternatives difficult.Other complementary options suchas touch, reflexology, massage, andacupuncture are benign and do seemto improve quality of life.[45] Perhapsmost frustrating of all to oncologists,is the acceptance by some patients ofseemingly fraudulent or difficult-tobelieveclaims (especially from theInternet), such as "He's not a doctor,but he says he's cured people the doctorshad given up on." Equally difficultto address are remarks such as"What have I got to lose?"This contention, however, can beseen as a model for negotiation in clinicalencounters. It is important that theoncologist listen respectfully to anytreatment strategy the patient hasfound or heard about and discuss it inappropriate medical terms, with attentionto the potential benefits andrisks.[46] A physician's unwillingnessto engage in this dialogue representsa barrier to effective communicationand ultimately damages the doctorpatientrelationship.SpiritualityThe importance of spirituality topatients varies greatly. It may increasetoward the end of life in some patients,particularly those who had relied onreligion and spiritual beliefs earlier inlife. A physician's ability to comfortablydiscuss such matters with patientscan facilitate and enrich the doctorpatientrelationship, regardless of thephysician's religious beliefs or levelof personal spirituality.For example, patients may ask,"Doc, do you believe in God? Will youpray for me? With me?" Whether thephysician chooses to discuss his or herown beliefs, assessing their importanceto the patient often opens a dialogueabout the patient's sense of hope,community, and deeper meaning oflife and death. While some view thisas beyond the scope of an oncologist's domain, a growing body of literatureconfirms the importance of these issuesin the patient's formulation oftreatment plans and expectations ofoutcome.[47,48]FamilyCancer at any age is difficult toaccept. It affects not only individuals,but families as well. When they hearoverwhelming news, patients frequentlyask, "How do I tell my family?How do I tell my children?" Someoncologists speak with the family aswell and assist in this difficult process.Cancer patients with young childrenare particularly poignant. However,most oncologists have not beentrained in the understanding of howcancer affects a family and how it affectschildren. Paula Rauch suggeststhat failing to discuss how the childrenare dealing with a parent's cancer isto ignore a crucial and dramatic partof the patient's experience.[49] Thelack of dialogue on this importanttopic can leave patients feeling overwhelmedand abandoned.Why do so few oncologists discussthese issues with their patients? Perhapsit is because they have not beentaught to or do not have the tools todo so. Rauch teaches the "basics ofchild development" necessary to havethis conversation with patients.[49]Understanding how a 2-year-old childconceptualizes and relates to theworld, and how that differs in a childaged 7 or 17, helps guide a patient touseful approaches to talks with his orher children. Offering this insight topatients is another way of reinforcingthe doctor-patient relationship.Cultural DiversityNo matter where one lives or practicesmedicine, one encounters differentcultures and beliefs about cancerand treatment. While this is an enjoyableaspect of interacting with peoplefrom different backgrounds, it can alsobe challenging. Wide distinctions betweenpaternalism and autonomy indecision-making in American medicinecompared to other societies cansurface in clinical situations. For example,although there is strong adherence Cultural DiversityNo matter where one lives or practicesmedicine, one encounters differentcultures and beliefs about cancerand treatment. While this is an enjoyableaspect of interacting with peoplefrom different backgrounds, it can alsobe challenging. Wide distinctions betweenpaternalism and autonomy indecision-making in American medicinecompared to other societies cansurface in clinical situations. For example,although there is strong adherencein the United States to the patient'sright to autonomy and to withhold thediagnosis and information from thefamily, patients from other backgroundsmay expect decisions abouttheir illness and treatment to be madeby their family, with differing degreesof their own involvement."Don't tell my mother!" the patient'schild sometimes insists. It mayor may not be possible to honor thisrequest, but again, it represents an opportunityfor discussion, to learn moreabout a patient's and/or family's beliefsand expectations. In many cultures,the custom to withhold the diagnosisfrom the patient persists. A familyfrom one of these cultures can posea problem to the treating oncologist.Perhaps the easiest approach to thisdilemma is to include the family in adiscussion, where the physician asksthe patient what he or she would liketo know. Most families that don't wanta loved one to be told about the diagnosisare acting out of a belief that theindividual would not want to know.Few continue to request silence whenthe patient articulates a desire to know(or, more often, states that he or shehas known all along but did not wantto upset the family with such an admission).Moreover, when a patientdoes decline information, oncologistscan easily respect the patient's requestto discuss such matters with the familyinstead.SummaryWe have outlined several clinicalscenarios that pose particular challengesto oncologists, with the goal ofhighlighting psychosocial issues fromboth the patient's and the physician'sperspective. Our aim is to offer insightinto, and tools for, an enhanced dialoguebetween patients and their oncologists.Increasing evidence suggests the importanceof communication skills inestablishing and maintaining a strongdoctor-patient relationship, and it is thedoctor-patient relationship that manyoncologists perceive as the most rewardingaspect of clinical care.[11]Physician stress and burnout arereceiving increased attention, as is theprocess of renewal. Holland's survivalguide recommends the use of humor,protected time away from work (withfamily and by oneself), and attentionto the level of stress and burnout inoneself and colleagues. Equally importantis maintaining a forum for discussionof these issues. This forumtends to occur most naturally with colleaguesin oncology, who understandand experience the same issues daily.The enrichment of the doctorpatientrelationship, through goodcommunication, can be viewed as theultimate coping skill for dealing withthe stresses encountered in clinicaloncology.

Disclosures:

The authors have nosignificant financial interest or other relationshipwith the manufacturers of any productsor providers of any service mentioned in thisarticle.

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