7/27/2019 Burnout in Cancer Clinicians--The Demoralized Clinician

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Burnout In Cancer Clinicians:

The Demoralized Clinician; The Demoralized InstitutionDavid W Kissane, MD

Objectives

1. To understand the nature of burnout in oncology2. To understand factors in providers, patients, and the work environment protective and predictive of burnout3. To review self care principals and explore advocacy approaches when concern exists about burnout in

colleagues or team members

When clinicians experience a progressive loss of energy, commitment and purpose in the care of their patients, leadingto role dissatisfaction, exhaustion and negative attitudes towards patients, colleagues and self, burnout should beconsidered. Studies have repeatedly shown that up to 25% of oncology staff are at risk. Warning signs include lowmorale, loss of satisfaction, boredom, fatigue, insomnia, decreased empathy, relational difficulties and absenteeism.

Maslach in studying burnout recognized that distancing processes which become habitual in the clinician reduceempathy and protect the clinician from emotional involvement and risk of exhaustion. So entrenched can thesebecome that the well defended clinician lacks insight into this depersonalization process and continues withoutsensitivity to the patients needs.

Burnout can certainly lead to established psychiatric disorders in practitioners, including depression, adjustmentdisorders and post-traumatic stress disorder. More commonly, the signs are subtle, with reduced idealism, negativity,loss of energy and a critical stance about others predominating. When this develops into negative attitudes towardspatients, the danger exists that the demoralized clinician will deliver poor medical care. Conversations in the staff roomthat express disgust, pity and intolerance indeed a host of negative attitudes towards patients highlight thepresence of burnout.

Demoralization is contagious and easily transmitted from patient to family to staff to doctor to nurse. A demoralizedmultidisciplinary team ceases to see the point of continued care provision and transmits an attitude of hopelessnessand helplessness to its patients. Training, skill development and communication are important counterpoints to suchdevelopments.

Vulnerability factors include lack of supports, personal vulnerability towards depression and substance abuse,propensity to self medicate, high expectations and sometimes a compulsive need to care. Role strain inevitablyemerges. When symptom management in the patient is difficult, toxicity occurs, interpersonal difficulties abound or

the family in the background is dysfunctional, the setting is ripe to deteriorate and the patient can be readily blamed.Poor teamwork, rivalries, work overload and inadequate resourcing quickly confound these problems.

Self-care is crucial. Holidays, interests outside of work, colleagues to debrief with and limiting workload realistically isvital. Variety in what one does is helpful. Most importantly, adequate education and skill development bringsprofessionalism to the role, which needs to be constantly updated through conference attendance and continuingmedical education.

Openness with our colleagues and advocacy when concerns arise are leadership skills that sustain a healthy workenvironment. Team exercises help to not label any individual, yet can promote insight and improved care. Isolated,solo doctors may be especially vulnerable. Palliative care teams have made use of multidisciplinary support to sustainmorale, brainstorm the management of difficult patients, debrief together and extend support beyond the narrowboundaries of the team.

Finally, institutions have responsibilities to adequately resource, train, remunerate and support their staff. Effectivecommunication and quality assurance processes sustain teamwork and productivity. Good staff morale is a marker of

safe institutional processes; demoralized hospitals breed poor standards of care and disgruntled staff members whostruggle to survive, let alone care.