The ASCO Education podcast continues the conversation on burnout, this time with a focus on how it affects trainees. This week's episode features Drs. Anna Laucis (University of Michigan) and Daniel Richardson (University of North Carolina). If you enjoy this episode, please subscribe or leave a comment.

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Air Date: 7/14/2021

TRANSCRIPT

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ANNOUNCER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

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ANNA LAUCIS: Hello. And welcome to ASCO Education's podcast episode focused on the important and far-reaching effects of burnout among oncology trainees. My name is Dr. Anna Laucis, and I'm a radiation oncology resident physician at the University of Michigan.

DANIEL RICHARDSON: And I'm Dr. Daniel Richardson. I'm an assistant professor and leukemia doc at the University of North Carolina. I recently completed my hematology-oncology fellowship here at UNC as well.

ANNA LAUCIS: So, Dr. Richardson, what has been your personal experience with burnout in your medical training and your current professional role?

DANIEL RICHARDSON: Well, that's a great question and something that I'm excited to talk about today. So burnout can really be expressed and experienced in numerous ways. Traditionally, we've segmented-- excuse me-- this into categories of emotional exhaustion, cynicism, and feelings of inefficacy. And one of the first things to mention is really the structure or the practice of medicine itself. I really see in most places that medicine continues to be very hierarchical and rigid. And this hierarchy and rigidity can lead to depersonalization.

I feel like we have a tremendous opportunity to connect with patients so many times in their darkest days, but we're taught that we can't show vulnerability and we need to act in a certain way. We are conditioned really to place boundaries around ourselves to depersonalize as a way to get through rounds, as a way to improve efficiency.

I know you've probably experienced this, but on the inpatient wards on morning rounds, we go from room to room. We listen to patient stories about the devastation that cancer has caused on them, but we don't talk about it, and we don't allow empathy really to come with us into rounds, and we exclude emotions altogether.

I think about, as a leukemia doc, the challenges when some of my patients die, and we don't talk about that. We don't talk about those challenges. We don't talk about our own emotions as we go through that process. And I often comment to others that I walk through the Valley of the Shadow of Death with most of my patients, and this human connection that we can have in the midst of that is so important. It's truly a sacred space where we can invite our patients into. And this process of walking with patients through that can bring about great meaning and satisfaction.

ANNA LAUCIS: Yeah. I fully agree. I think there are many ways in which we connect with patients. And I think that's really important, as oncologists, whether radiation oncologists or medical oncologists or surgical oncologists, is the ways in which we connect and empathize with our patients. It's not only, I think, the greatest gift and support we can give to patients, but also I think, unfortunately, can also really lead to burnout, especially it's difficult to set boundaries sometimes.

We really invest in our patients, and we almost take personal responsibility for their outcomes as well, even though, as I've gotten further in my training, I've realized that, unfortunately, there's just really bad biology sometimes, just really bad disease. And as much as we do, there is a limit to what we do. And I think that, as I've gone through my training, I recognize that being able to set boundaries, however difficult that is, while still empathizing, having a way to find meaning and purpose outside of work is so important as well and can help reduce that burden of burnout.

And one of the ways I've conceptualized this is we absorb these collective traumas, as you mentioned, walking from room to room in the hospital ward, for instance, in the clinic in radiation oncology. But going from room to room, I try and take a second, and whether it's washing my hands or just taking a moment to reframe, it really helps to set that boundary not only between the patients and ourselves but also between patient to patient, because it is so important that we give as much as we can to our patients but also that we find ways to refurbish and refill this bucket of energy and dedication that we have.

DANIEL RICHARDSON: Yeah. I think your point about finding identity in your job, I think is-- it's both a double-edged sword. I'm a huge proponent of finding meaning in medicine and then really finding ways for us as a community to find meaning in medicine. But also, if we find our whole identity in our work, it's really going to become an idol in our lives, and it's going to inevitably fail us.

I think trying to use work alone to sustain our deep need and purpose as a human being is probably not enough. I find that work has a place in my life and has a place as, many times, our calling. However, I don't think it can fill every aspect of it. And if we try to put that onto our work, even a tremendous calling such as oncology, it's inevitably going to fail us.

ANNA LAUCIS: Absolutely. I agree. And I think one of the things that to keep in mind is that whether I think in medicine in general, but in particular oncology, it really stretches us to our full capacity in training, and we give it our everything. And I think sometimes, as I've touched in conversations with other colleagues, sometimes we give it so much of our all that other elements of ourselves that made us interesting and dynamic and multifaceted in high school, college, medical school, cooking, exercise, all of these things that we do to be a complete person, some of that does, I think, by nature of the intensity of our training, especially in oncology, does get pushed to the side.

But I think it's important as much as we can to find ways, even if it's small, even if it's small amounts of exercise or small amounts of cooking or enjoying other aspects of our life, to reintroduce to us when we're able to in training, because I do think it allows us to bring our full selves to work and to connect with patients in the best way we can as well.

And I think one of the things that I love the most is being able to bring a smile to a patient's face, even though they are in a very vulnerable time. All of our patients pretty much have cancer. But like for example, the other day, I connected with a patient about going to Harry Potter World and Disney, and that really brought a smile to his face, even though we were dealing with a metastatic cancer for him. But I think that really brings meaning and also is so important to do to be able to connect.

DANIEL RICHARDSON: Yeah. So I want to jump off two points. So the first one you said, how do we have these repeated traumas in our lives, and how do we manage those? I think this repeated trauma or this repeated suffering that we experience on as part of our jobs really erodes our ability sometimes to engage into our own lives and engage in the lives of our patients.

And I think about as oncologists we often are mediators of life-defining information. We often tell patients that they have cancer, that they aren't going to survive the next couple of years, that they need to make decisions to prioritize as we move forward. And we can feel like we are the mediators of devastation to our patients.

And I think, as we've mentioned, one strategy is to build these deep, impenetrable boundaries, where we don't allow that suffering to seep into our souls. Sometimes we talk about resilience, but I think that, as you mentioned, too often, we can hide in our boundaries and not allow that connection to happen. And I think, as you mentioned, these small things that we can begin to do-- we can begin to connect with patients to give them good-- I really think that this is developing a strategy of redemption rather than resilience alone. That is, we can learn how to find great meaning, purpose, and satisfaction of walking through the suffering with our patients rather than simply learning to endure it as a side effect of our lives.

And this really comes from embracing, caring for the suffering as a calling, and finding ways to bring good into the lives of patients in the midst of their suffering. So you mentioned talking to them about Harry Potter, getting to know them. Perhaps it is just this listening ear. I think oftentimes patients have a tremendous story to tell, and allowing them to tell it or walking them through it is so important. Perhaps it's a prayer. Perhaps it's a hug. Perhaps it's just the acknowledgment of the loss that they're experiencing and finding those connections with patients and bringing good into their lives in the midst of the suffering that they are experiencing is so important.

ANNA LAUCIS: Yeah. I fully agree with you. I think that's one of the greatest gifts that we can give as physicians. And it reminds me of-- so I did a lot of art history in high school, really enjoyed that, very different from medicine. But I think one of the interesting things-- and I'd love to take a specific course some time on just the history of medicine through the lens of art-- it just reminds me of this famous painting of the physician at the bedside of a patient, holding their hand. And in those days-- this was way back in the early times where medicine was really more about just the physician at-- the word "attending" comes from just attending to the patient's needs.

And I think that sometimes we get so tied up in learning all the clinical trials or all of the oncology outcomes, but I think that, at the core of it-- and I know that the ACGME has an initiative, Back to Bedside, and trying to find the joy in medicine that I think there's a lot we can offer just as a fellow human, as a fellow person who brings their redemption, hope. And I think it's important to draw the line there, especially in oncology, to not offer false hope, but I think to give as much support as we can to patients, because it is a very vulnerable time. And yeah, I think patients have very interesting stories, just getting to know them, even if it's asking about their family or things that are important to them.

Or I try and recognize if patients are wearing a shirt with a logo on it and I recognize that, I try and bring that up, and you often see their face light up. Like, a patient recently loves the Detroit Tigers. And so he was having horrible nausea a bit. Then, talking about the Tigers, his face lit up, and he forgot about the nausea for a moment. And so even just those moments of peace that we can bring to patients, I think that, for me, at least helps combat burnout because I really find a lot of purpose and meaning in that. And I know that, at least in that moment, I gave that patient some peace and some joy perhaps.

DANIEL RICHARDSON: Yeah. I think that's really important as we think about our role as co-journer, as people stepping alongside and walking with patients through their journey with cancer. Obviously, we'll have opportunity to experience great joy for some patients and great sadness for others. So I think that is really an opportunity for us to enter into those experiences with our patients.

I'm interested on your perspective on how COVID has really impacted your experience of burnout or other aspects of training for other residents.

ANNA LAUCIS: Yeah. I would love to touch on that. So I think that COVID has been very interesting from the standpoint of just completely turning on its head everything that we thought was important about, I think, medicine, our experience. Even the didactic structure, that was one of the early changes that all of our didactics became virtual. In a sense, that took away some pressure, where we rotate between multiple sites in our training program.

And that was actually one of the stressors before COVID was having to drive physically from one site to another or even in our research block and having it-- for me, I live 20 miles from my work. So having to drive that far a distance-- so that was a silver lining of having a little more flexibility there.

On the other hand, I think that one of the challenges it's brought up, particularly in the context of burnout, is that I think one of the aspects of wellness and a culture of support is truly those person-to-person interactions, especially amongst trainees. That is more of a sense that we're all in this together. And especially, if we're all in the same work room, we can bounce ideas off each other or really help provide at-the-elbow-support, especially for the junior residents. That's so important. And definitely an aspect of that, I think, was challenging.

Even like happy hours-- we would do a lot of those before COVID in person and just as a way to relax, relieve stress, but also connect as not just coworkers and colleagues but friends. And really, I think those friendships then lead themselves to being able to support each other better at work as well. And so I'd say that's one of the challenges has been finding ways to still connect in different ways than in person or doing virtual happy hours, so it's not quite the same.

Then I'd say the other element of this-- and I've really seen this firsthand in terms of taking care of my patients. So one of the first things that happened was visitors were no longer allowed to accompany patients. And many of our cancer patients are elderly or have deficits, and they often really rely on those family members not just for physical support but also to take notes or to help them keep track of appointment details.

And so even if we teleconference those family members in, it's not quite the same support as they would have by having their family member there in the room, especially for emotional times or if the patient's bringing up very difficult things. Even if we can offer a tissue or give some space for emotion, it's not quite the same as just holding the hand of their family member or something like that.

And then I'd say the other aspect-- just a brief personal story I have is that a difficult experience I had recently was I helped a patient get through a very difficult treatment, seven weeks of daily radiation treatments, and talked to that patient or his family member pretty much every day of those treatments. He was having a lot of symptoms.

And then it was so unfortunate that I saw about a month later that he had actually passed away from COVID and complications of COVID. And just to have, I think, put all that-- because I think, especially, this idea of defining your worth and your purpose from the outcomes of patients, that was really a crushing moment for me, I think, that I was like, wow, we got him through all of this treatment, and then for COVID to-- just this existential anger at COVID.

DANIEL RICHARDSON: Yeah.

ANNA LAUCIS: Why did that happen? But I think on the positive side, I guess, getting back to silver linings was that I had actually thought to call that patient's wife and offer my condolences and to see if she'd be interested in a bereavement counseling because I knew we offer that service, and I was actually the first person to reach out to her to offer that. And so I felt that even though it wasn't as much closer as I would have liked, at least I was able to offer something. And I think that's what can help lead us forward in those moments of still being able to offer ourselves to support and to provide. Even though we can't of course give her husband back, at least give what we can.

DANIEL RICHARDSON: Yeah. So obviously, as we're talking about burnout, thanks for sharing that that was a crushing time, and that's OK. I think that sometimes the loss of our patients is crushing and can feel crushing, and it's emotionally challenging. So thanks for sharing that.

I think that you had mentioned a couple of things about the silver linings of COVID. And I think one of them is really this emerging understanding of the importance of addressing well-being. COVID has been a shockwave that's gone through our medical system, and we've seen providers really wrestle with the ongoing suffering. And so bringing this to the fore is really important.

I have really benefited. So I have a young family at home, and so I benefited quite a lot from the ability to work my non-clinic days at home. And I really hope that that continues to be something that comes out of this-- so the televisit, working from home. And I'm hopeful that we continue to see well-being as a central aspect of caring for patients well and delivering really high-quality care.

So obviously, burnout is a very serious issue, and as I just mentioned, we don't often talk about how challenging it can be to walk with patients through suffering. What kind of strategies do you think work well in supporting wellness and preventing or mitigating burnout?

ANNA LAUCIS: I think there's a number of ways to think of this. I think that, often, personally, in efforts I've led or what I have seen, there's almost this stigma in general about mental health issues but, in particular, about wellness. I think you had mentioned your resilience earlier that I think sometimes this-- especially in medicine and I think in other industries as well, there's almost a stigma against wellness efforts because we think about it as like putting the onus on the individual to build resilience and to add one more thing to their plate or do one more wellness module.

And I think actually one of the drivers of burnout is that we're already-- our plate's already overflowing with responsibilities, and actually offloading some of those might-- I think is, in general, a more successful strategy than adding things to it.

But I think it's challenging to do that, right? We can't necessarily take away the important work that we're doing in oncology. And as we were talking about we're walking with patients on this journey, we're kind of absorbing their traumas. We can't really take that away, necessarily. I mean, that's essential to what we do. But I think one of the ways that we can address it-- and what I found to be successful in my own efforts here in my training program-- is just thinking about, OK, I think there's-- even though we've been in all together, I think there's really a lot of different drivers, and addressing each one individually is important.

So for example, thinking about, OK, what's on our plate that's overflowing, and is there excess of those things? And I think that COVID, again, has maybe helped us think through that.

OK, maybe we don't need to have in-person didactics that are stressing us out and making it difficult for us and maybe some of-- because I think, for a virtual Zoom meeting, it's a little easier to log off or put yourself on mute if you have a child or a pet that needs something or even-- yeah, and as you talked about this flexibility of working from home part of the days, even getting to doctor's appointments or dentist appointments, that's an issue that trainees certainly have as well. And so just being able to attend to your personal needs better, I think that's a way of-- it's not necessarily taking something off your plate, but it's making something a little easier to do.

On the other hand, I think that really successful wellness initiatives that I've seen really addressed burnout from the grassroots rather than top down. And so I think if it's just another one of these online modules that we do that I think a lot of us click through quickly just because there's so much, I think that that's not necessarily the most successful. But if it's really maybe a group discussion or thinking about, OK, maybe, especially in oncology, one of our issues is that we don't have a good outlet, and we don't really have a good, safe space to talk about death, illness, tragedy, all of these big, big heavy themes that we're dealing with daily.

And so, actually, one of the things I've been able to implement at my institution that's been very successful is adopting this national platform called Schwartz Rounds to the radiation oncology setting. And the idea of this is to give a safe space for talking about the emotional, sociodynamic, truly community and also complexities of care that it's not just the patient in front of us and their oncologic outcome, but also the difficult family dynamics that sometimes arise in patient support as well as ethical dilemmas that can arise.

But I've started at my institution is something called Radiation Oncology Reflection Rounds, and that really has given us a safe space. And we did do a virtual version of that as well recently, which went well. But this idea is we all sit around and think about the emotional and interesting impacts that dealing with cancer patients has and also the ways in which we do have an outlet to talk about this.

And so these sessions have often involved even leaders in our department bringing forth their emotions in a way that I think is really impactful and sets an example that this idea of it's OK to not be OK, and we don't often talk about that enough. But that has been very meaningful. And I think you, hopefully, will continue on after I leave here. And I think the national Schwartz Rounds platform as well really accomplishes that in a multidisciplinary way.

DANIEL RICHARDSON: Yeah. I think a few things that are really profound is providing the opportunity to share emotions and have a safe space. I think, too often, we don't have safe spaces in medicine to say we're not doing OK. The buy-in that you got from upper-level leadership and the mentors, those that establish the culture, is really important. I really believe that, as we build a sense of community, a shared sense of purpose within our institutions, within our organizations, within the broader community of oncology, that can be a powerful mitigator against burnout as we feel like we are in it together, that we feel like we are contributing to the greater good. That's so important.

I've been privileged to develop an art of oncology program at my institution with others in psychiatry and palliative care, and it's a similar idea to allow for a fellowship program to provide a place to share our stories, to reflect on some of the more challenging issues in oncology, to reflect on suffering, to reflect on communication, to go into those places that it's really hard for us to talk about.

And one of the things that we've really seen come out of that is the shared sense of meaning, this deeper connection and this understanding like, oh, you're walking through that too. And it's OK to share that this is really hard, and I don't have all the answers. And, oh, man, I don't know what to do for this patient, and I'm feeling inadequate in my role as an oncologist or as in my role as a fellow. And it seems like everybody else is doing fine, and I'm not. And having the opportunity to build those connections with co-fellows and others in one's own institution is really important.

I think, for me, as I went through fellowship, there were certainly this sense that I needed to let go of things that we can't control and really saying it's unsustainable for us to think that we can save every patient, and really saying my goal as an oncologist is to, yes, deliver high-quality care, but it's really important for me to care for each and every patient, to get to know them, to get to know what's most important to them, and to let go of the burden on their outcomes.

I can't pick and choose which patients the chemotherapy is going to work. I can't pick and choose who's going to have the best outcomes, but I can serve and care for each patient. And by doing so and having the opportunity to walk with that for patients, I can get a deep sense of purpose and meaning in the lives really of each patient.

ANNA LAUCIS: I think that brings up a few really important points, and I think one of those-- and it really resonates with me what you said about letting go of what you can't control. And I think that goes for not only patient outcomes but also just everything that comes with the work we do in medicine. It's often very busy. There's often many workflow issues that are beyond our control, or the patient showed up late, or then they're not roomed in time, or just all of these workflow things. And I'm sure on the inpatient side as well, as I saw in my intern year, certain labs taking longer than they should to come back or various things that there's just all-- it's really a lot in our profession, I think, that's outside of our control.

And so I'd say that I agree that one of the ways that I've been able to really cope with these issues of burnout, the best has been-- and I think a successful strategy, in general, for these issues and challenges in life is being able to walk back from that and say, OK, set a boundary like a mental boundary. OK, what's in my control, and what's not?

And I think some of these inspiring quotes that have really resonated with me are these ideas of saying, OK, what are the things I can control? I can control that I show up on time. I'm compassionate for my patients. I'm taking care of myself right-- sleeping, eating, the bare-bones essentials. And yeah, I'm going to be a supportive colleague for my co-residents. I'm going to help them out when I can.

But you know what, at the same time, I'm human, and I'm going to inevitably make some mistakes. But I can't dwell on those or beat myself up about those, because you know what, I need to be able to bring my whole self to the next patient. And I think that's really been a healthy approach for me, and I've been able to really overcome a lot of barriers that way, being able to say, OK, all of these extra things that are going on, whether it's the patient's outcome or the workflow concerns.

And I think humor too can be helpful, even if it's cynical humor, saying, well, of course, on a Friday, I'll get three urgent patients that I need to essentially stay overnight to treat. That happened on my last call week, but the good thing was the supervisor who was on call with me and myself, we just approached it with a smile, and yep, OK, this is Murphy's Law. I know it's going to happen this way. And I think that can truly help these, again, existential things. Well, you can't control this, but of course, that's going to happen this way.

And so I'm curious as to, for you, Dr. Richardson, what other strategies you've had in personally coping with burnout in some of these issues as well.

DANIEL RICHARDSON: So I think that you mentioned about coming at your patients as a whole person. And I think that that's really important. I am a huge proponent of thinking as a community of how I can find meaning and purpose in our work. But as I mentioned before, this work can't be all that we have. So I think it's critically important for us to establish patterns in our lives of rest, of quiet, of rejuvenation in order for us to come as whole people back to our patients and back to our colleagues and coworkers.

For me, my Christian faith and my family are tremendous sources of strength and encouragement. And I really think that it's important that, as a community, we recognize that, as whole people, as we come to our patients, we need to encourage the others to find those places of strength and encouragement outside of medicine, even if that means, yes, we need to encourage vacations, even if that means we take call for other people so they can establish better patterns of rest, et cetera.

ANNA LAUCIS: Yeah. And I would echo that as well that, really, and I think too of this idea of redefining what success means as well. And I think whether it's medical oncology, radiation oncology, surgical oncology, really, all of us are very high achievers, and we're used to not only being able to, to some degree, control the outcomes of our own successes based on the effort we put in.

I think one of the true challenges of a field like oncology is that, regardless of how much effort we're putting in, how many extra hours we're putting in, that sometimes just the biology is very challenging. Some cancers-- and by now, at the end of my training here, I've learned which one is that, OK, if the pathology comes back, it's that. OK, I'm going to have to really reframe my discussion with the patient and, again, this idea of not giving them false hope.

But at the same time, I think, really, there's a lot of tools from palliative care and this idea of, OK, this is a difficult situation, but we're going to fight it with everything we can, and this idea of even if we can't cure your cancer, we're going to be able to use support to help you feel as well as you can for as long as you can. And so I think that having more tools in the toolbox, I think that rather than this naive thinking of, oh, the only good outcome for a patient is cure, really, I think-- and especially in palliative care rotations I've done-- and it sounds like you've had a lot of experience in that as well-- this idea of a good death or this idea of patients really meeting their goals and what they value.

And I think really digging into that, it can not only help us really give our best efforts for the patients but also their family members, and also just, again, reframe this idea of what's a good outcome. And in some cases, the patient will succumb to their disease, but if we can offer them peace, better time with family, reconciliation of difficult family dynamics, or just reduced nausea, reduced headaches, reduced fatigue, I think all of that can be considered a success.

DANIEL RICHARDSON: Yeah. I think it's a great point to say that we cannot define our success by the clinical outcomes of our patients. I personally define success, and I encourage residents and others that work with me of saying, let's care for each patient. Let's deliver quality care to our patients and care for them.

So that is all the time we have for today. I want to thank Dr. Laucis. This has been really great. I think, as we begin to allow COVID to bring up wellness and well-being into the forefront of our minds, I think we have a tremendous opportunity to engage each other on furthering this conversation for how we can better mitigate this in our community and develop a deeper sense of community and purpose as an oncology community.

So it's been a wonderful conversation. Thanks for listening to this episode of the ASCO Education Podcast.

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