Cancer Topics - Burned Out? Here's What You Can Do About It (Part 2)

In the second of ASCO Education’s two-part episode, Todd Pickard, MMSc, PA-C (MD Anderson Cancer Center) continues the conversation with Drs. Daniel McFarland (Northwell Cancer Institute), Sayeh Lavasani (City of Hope), and Fay Hlubocky (University of Chicago) about individual and institutional interventions to prevent and address burnout among oncology professionals. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: elearning.asco.org | Contact Us

Air Date: 6/30/2021

 

TRANSCRIPT

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SPEAKER: 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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TODD PICKARD: Hello, and welcome to the second ASCO eLearning podcast episode focused on burnout in oncology. In the previous episode, our guest speakers discussed what burnout is, its warning signs, risk factors, preventative measures, and talked about their own personal experiences with burnout. My name is Todd Pickard, and I'm an oncology physician assistant at the MD Anderson Cancer Center.

I'm pleased to introduce our three guest speakers as we continue our conversation on the prevalence of burnout and its implications for personal well-being and professional satisfaction. Dr. Fay Hlubocky is a clinical health psychologist and research ethicist at the University of Chicago Medicine. She's also co-chair of the ASCO Oncology Clinician Well-being Task Force and has extensive research experience in burnout.

We're also joined by Dr. Daniel McFarland, a medical oncologist and consult liaison psychiatrist specializing in head and neck thoracic malignancies and psycho-oncology at Northwell Health Lenox Hill Hospital. He has conducted research on empathy, resilience, and distress in trainees and edited an upcoming Springer book publication entitled, Depression, Burnout, and Suicide in Physicians.

And finally, we are also joined by Dr. Sayeh Lavasani, a medical oncologist specializing in breast cancer and an assistant clinical professor in the department of medical oncology and therapeutic research at City of Hope.

Dr. McFarland, you mentioned that you've been involved in research on burnout. So tell us, how prevalent is burnout in oncologists? And is it getting better or worse?

DANIEL MCFARLAND: Thanks, Todd. Yeah, good question. The research that I did was more on empathy, resilience, and distress, not burnout. I didn't actually measure burnout. But the latter part of your question, I'll tell you that some data indicate that it is increasing. In general, oncologists are in the middle of the pack in terms of medical specialties and where they fall in terms of how burnt out they are. And it really speaks to the drivers of burnout being not always what you think that they might be.

As a specialty, we see a lot of the patients at the end of life. But as has been mentioned, these are really more systemic, administrative of issues, although it can be communication. And again, it's just everyone is a little different in that regard. So whether it's actually increasing or we're just having more attention to it is probably a good question. But either way, it's there, it has been there, it's a problem, and we should do something about it.

TODD PICKARD: So Dr. McFarland, I really like the fact that you just said we should do something about it, and that leads to my next question. Is there any evidence-based interventions that we can use to prevent burnout?

DANIEL MCFARLAND: Absolutely. There are several good meta-analyses in fact. So people have been looking at this across the board. The caveat is that they're not always specific for the setting. And I don't think there is a way to make that necessarily possible, given the multitude of settings. But in general, across the board, doing something seems to be better than nothing. The issue is, well, are they durable responses? And what exactly are you measuring?

So if you have a drop in burnout by two points, is that enough? It looks like actually even a few points-- and I think it's around four points on the Maslach scale, MBI, Maslach Burnout Index. Fay can correct me on that, I guess. But if there's just even a small drop, then that has been shown to be a meaningful change, which is wonderful.

Now in sub-analyses in these meta-analyses, they've shown that the kinds of interventions that are most effective are organizational interventions. And most of those types of interventions are things like work hour restrictions and workflow modification. But the big caveat there is a lot of those were done in trainees, where they would have work hour restrictions. So again, you have to sort of take the data for what they are. And if it's applicable, then great. If it's not, maybe try something else.

So the take-home message is that the organizational type interventions are not only more efficacious but seem to be longer lasting in their efficacy. But that doesn't mean that individual interventions don't work, because they do. They also work. And I would say from the sub-analyses that I've seen, if the interventions incorporate mindfulness or some part of CBT-- that's Cognitive Behavioral Therapy-- those interventions seem to work the best.

The combination would be ideal of organizational changes with individual types of changes. And a lot of this comes down to sort of system-based changes. I think of adaptive trial designs, that's essentially what's needed. One thing's going to work in this setting, another thing will work in another setting. Each field has its own drivers of burnout.

I'll tell you, for example, totally outside of oncology, that with psychiatrists, who, again, don't have the highest rates of burnout for probably the reasons that we talked about, but actually violence. A lot of psychiatrists have been hit by a patient or had violence thrust upon them. And it's a real cause of burnout. I just would have never exactly put that together. So the point is that for each discipline, there are specific things, and then there are general drivers of burnout. I think we all work with the electronic medical record. We all have bosses and administration that we work for. And so it's a matter of putting these things together.

TODD PICKARD: Yeah, it resonates with me that there's a lot of things that we hear about, but then there's a difference between understanding what's out in the literature, what you hear articulated, but then how do you turn that into practical methods. Dr. Hlubocky, how can our listeners adopt some practical methods for preventing burnout that's easy to implement?

FAY HLUBOCKY: Thank you. Awareness and education is key, truly being aware, truly being motivated. We talked about self-assessment. That was actually one of the first strategies that we described in our educational book in 2016 with Dr. Back and [INAUDIBLE] of really doing, as Dr. McFarland talked about, really doing that self-assessment. 1 to 10-- how irritable, how sad, what am I? Rating that, and not just rating yourself multiple times a day, having a barometer. And again, asking that trusted observer, maybe it's your wife, maybe it's your colleague. And then, of course, to seek support if that is needed if it does become too extreme. But clearly, we know awareness and education is key-- education.

So some of the early internal medicine work showed that a simple one hour educational talk on burnout, on well-being not just informed the attendees but also compelled them to practice preventative behaviors. What was that? Exercise, getting better sleep, trying to leave work on time if they were able to, better nutrition. It is these simple things. I work with oncology fellows and teach them communication. And we have a formal burnout and compassion fatigue course.

And that is what we did in one study was just do an education, a little didactic, six months later evaluated them using the protocol and the MBI. And similarly, they changed their behaviors. They changed their practices, even the qualitative responses told us. So education is so key. And I motivate leaders so much to simply have a one hour [INAUDIBLE] grand rounds on burnout. Get some CMEs, so it motivates the docs to come in and to attend and to learn, because it is only through education do we know what to look for and what to address.

Self-care is critical. I cannot emphasize that enough. Yes, burnout is an occupational phenomenon, without a doubt. But in order to find meaning and joy and purpose in your work again, to find, to research, to rekindle that joy that you have, you have to practice some techniques. So again, it's these preventative behaviors, again just basic needs of sleep and nutrition and exercise, but it's also things like writing a narrative. When you had a patient case that maybe went a little bit south, write a little narrative about what happened so you can be self-reflective of that. Journaling, talking about that patient's story, that patient's story that went well, that patient's story that went really bad.

Gratitude-- gratitude is kind of a newer phenomenon coming out, but we teach docs to just name three things that you're grateful for in the morning, in the afternoon, and before you go to bed. It's a way of seeking self-compassion and kindness where you haven't been.

Mindfulness-- Dr. McFarland talked about mindfulness. My conflict of interest is that I am a mindful teacher. I teach this with patients and with my colleagues and students. It is intentional, purposeful. It's not about sitting in the corner and doing some yoga and breathing, but truly teaching the docs, teaching my colleagues to do some breath work before they start their EMR, right? Mindful handwashing techniques of really taking the time when we're washing our hands, a real contemplative practice to be able to recharge and refresh during that course of the day.

Although self-care is critical, and I view it very much as it being your life preserver, sometimes when colleagues say it's my organization that's really beat me down, it's not my fault I'm burnout, my analogy is, gosh, if you're on a sinking ship, won't you use your life preserver? That's what self-care is. But equally important is for the organization to please provide that support, to empower the oncology clinician to use the team. So many times I encourage the colleagues to use your team members. We're all in it together, but to truly work together as a community, because it's only as a community we'll be able to address this issue in that. So truly, self-care is vital without a doubt, can't say more than enough about it.

TODD PICKARD: So many things that you just said resonate so strongly with me, that sense of community where you feel like the stress and everything that you're going through is shared and that sense of gratitude. Just thinking about a few things that are going right, it just lowers the threshold. It lowers the stress. So let's stick with stress for a second. Dr. Lavasani, in your experience, what are the effective strategies that you've used or experienced to mitigate stress level that are helpful?

SAYEH LAVASANI: When I experienced burnout, then I decided to learn how to cope with it and to reduce my stress level. I realized that situation was not sustainable and I needed to take some action. So what I do is that I usually set aside one hour every night for myself to do things that I enjoy. It's like my me time.

So this could be cooking or reading a book one night, or watching my favorite show on TV or Netflix the other night. And also one way that I relax is by listening to music. When I'm tired of doing my administrative work or days that I'm in office, I just listen to my favorite song. It's just three to four minutes, but it makes me feel better, and then I go back to my work.

It's also, I think, it's very important to set aside some time to do exercise. If it's not possible every day, but a few times per week. And our nutrition is also very important as you know. Fay was mentioning as well. Initially when I started working as an attending, I was always skipping lunch in clinic. But then I learned that actually taking that half an hour break to have lunch helps me to feel better and to recharge, and then I can go back to my clinical duties.

And also, I try to stay organized and complete my tasks on time. It helps me to avoid procrastination. That really increases my anxiety level, because then I feel like I have unfinished things to do and just that it increases my stress. So I try to really be organized and to be on time for everything.

And this is something that is very difficult-- I'm learning to do that-- And that's basically to say no to unrealistic demands. Medical oncologists, like other physicians, we have learned to say yes to all expectations. This is something that we need to work towards unlearning. The expectations and demands on us is really high. And we feel like we always must serve others and their needs, including our institution's administration. We have turned into passive individuals, that we agree to whatever that is thrown on us.

Unfortunately, in a lot of practices, there is a disconnect between administration and physicians. And so it is very important to engage the administration to recognize burnout. And it can really affect productivity, and they need to come up with an action plan to help physicians to do things that will make our lives easier.

And definitely getting support from other team members, from our colleagues is very important. Our peers, they play a very important role in helping us and supporting us. And we always believe you are stronger if we stick together. So definitely, this is also very important to have that support system at fort.

TODD PICKARD: It's really important that when there is that disconnect between your practice, your institution, the administrators, and what the individual providers need, they've got to have a resource. And that brings me to my next question. This is where ASCO has actually something that might help. So Dr. Hlubocky, you're serving as co-chair for the ASCO Oncology Clinical Well-being Task Force. Can you walk us through the work this task force is doing? What kinds of tools and resources are being developed and offered?

FAY HLUBOCKY: Oh, thank you. It's such a privilege to introduce our membership to this wonderful task force that's in our infancy, and it's an honor to serve as co-chair with Piyush Srivastava. It was a collaborative effort between both the ethics committee and the clinical practice committee to gather a group of folks that are experts, including, for example, Dr. McFarland is one of our tasks force members, where we could actually focus on the oncology clinician well-being.

And how have we defined well-being is it's been adapted from the National Academy of Medicine's definition that it's this integrative concept that characterizes the quality of life that encompasses that individual's work-related activities, the personal, the health, the environmental, and the psychosocial factors as well.

And our mission is to improve that quality, the safety, and the value of cancer care by enhancing oncologist's well-being and the sustainability of the practice as well. We have a five-year plan. Our task force has a five-year charter and road map. The aim is really to promote well-being across the ASCO activities, diversifying resources to promote and identify the needs through research activities, to identify the needs of that individual clinician to improve the practice as well.

So ultimately, our vision is across ASCO to create programs and strategies that can really help the clinician, as well as I think the cancer organization as well. As I said, many leaders come to us wanting to implement interventions and not really knowing how to. So although we are in our infancy, we have been quite busy and we have developed a research page that all members can access that has empirical research on there and also some tools that could be used, multiple resources on there.

We also had a webinar to introduce the task force to the members-- of course the purposes and the charter. We also recently published an editorial in the JCO JOP talking about the impact of COVID on burnout, moral distress, and the emotional well-being of the oncologists. And that actually has multiple useful interventions that the organization might consider as well. And we just conducted a focus group study that is currently under peer review of the oncologist experience, both the personal and occupational experiences during the COVID pandemic, what is that oncologist going through.

So very busy. Again, in our infancy, we have lots of plans to hope and look forward to all of these endeavors, and of course, your feedback on it. We are here to help and serve you, and we are very grateful to ASCO leadership for giving us this opportunity to advocate for the oncology team.

DANIEL MCFARLAND: Can I just say one other thought that I had? When we were talking about the interventions, I was just going to say that one way that I think about the interventions that might be helpful is that there are some interventions that are sort of pulling the clinician away from the work environment, whereas others are having the clinician kind of engage more strongly with the work environment or in a different way. And the latter seemed, obviously, to be a little bit more effective or makes sense, because we've all had that feeling of being on vacation and you go back and it's the same thing. And so I just wanted to add that that's just another way of looking at the interventions.

I always talk about this study that was done in Oregon like 20 years ago, because it was so genius that what they did was they basically-- it's a group of five different community oncology practices. They got together and they said, OK listen, burnout's a problem. We're measuring it. You guys figure it out, and we're going to remeasure it.

And the beauty of it was that it addressed what some of the problems of burnout are-- feeling like you're in control, and then kind of having that engagement part where you're engaging with whatever you're creating to mitigate the burnout. And thirdly, it brought the oncologists together. So they had to figure it out in their own way and what made sense for them. And in my mind, that's the perfect solution. And it does help bring administration and clinicians together, because ultimately, we do all care about the same thing.

FAY HLUBOCKY: It's a great example of peer support, Daniel. We always talk about peer support. And I think a lot of folks say, what does that look like? Is that a group thing? And exactly that study of getting everyone together to talk about it-- how can we make change, how can we improve burnout at our organization-- is critical. That's why it really-- it can't just be leadership alone, and we need physician champions. We need lots of folks involved in the process to ultimately improve the quality of cancer care at that institution, and I think honestly nationally and globally. That's kind of what I think even our task force is about.

TODD PICKARD: Oncology is a team sport. We're all in it together.

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TODD PICKARD: Exactly. If we're taking the patient's care in all of our hands, well then we all have a responsibility for preventing burnout and backing each other up and talking about this and being that trusted person to be that barometer. So it's a team sport. No person stands alone.

FAY HLUBOCKY: Yeah, and the oncology clinician is the most compassionate clinician, I think, out there. Truly. Of course, I have a little bit of bias there. But truly, my colleagues are the most compassionate, kindest people, people I just love being around. But it's so tough to show self-compassion isn't? We're great at giving compassion to others, to the suffering, but to self that tends to be a little bit more difficult. So that's why we have to help all one another, as you said.

TODD PICKARD: Well, this has been a terrific conversation. So thank you Dr. Lavasani, thank you Dr. Hlubocky, thank you Dr. McFarland for your engagement and conversation today. That is all the time we have. But we thank all of our listeners today for listening to this episode of the ASCO e-Learning podcast. To keep up to date with the latest episodes, please click to subscribe and let us know what you think about the podcast, leave us a review, or email us at elearning@ASCO.org. Thanks so much, everybody.

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