The Side Effects of Caring: Dealing with Secondary Traumatic Stress in Oncology

Listen to ASCO's Journal of Clinical Oncology essay "The Side Effects of Caring," by Dr. Aarti Kamat, a pediatric hematology/ oncology fellow at the University of Michigan. The reading is followed by an interview with host Dr. Lidia Schapira and essay author Dr. Kamat, where they discuss coping with Secondary Traumatic Stress (STS) after Dr. Kamat has a triggering experience with a teenage patient.

TRANSCRIPT

The Side Effects of Caring: Dealing with Secondary Traumatic Stress in Oncology

Narrator: The Side Effects of Caring, by Aarti Kamat, MD (10.1200/ JCO.22.00736)

"I don't want to die in the hospital." I could hear the young teenager crying in the background as I told her mother on the phone that she should come in to the emergency department. She had recently been diagnosed with a relapse of her leukemia and subsequently developed a systemic fungal infection. She now had a new fever that needed to be evaluated. She had decided that her goal was to pursue all possible treatments and interventions, so although I knew the thought of going to the hospital was distressing to her, I felt that this was the safest course of action and in accordance with her overall goals of care. I gently expressed to both my patient and her mother that I did not think this would be a long admission or result in her death. I could hear the mother reiterating my comment to her daughter who continued to sob and repeat that phrase. "I don't want to die in the hospital."

Eventually, my patient calmed down. I convinced her that I had no intention of sending her to the hospital to die, and she was successfully discharged home after a short admission. Despite the objectively positive medical outcome, I would still hear the patient crying in my head at random moments. Whether I was lying in bed with sleep eluding me, walking outside with my dog, or caring for other patients, I kept hearing the phantom voice repeating the phrase, "I don't want to die in the hospital." I felt strained and stressed and was sleep-deprived while trying, unsuccessfully, to ignore the crying voice that was plaguing me.

As a pediatric hematology/oncology fellow, I have seen and dealt with my share of emotional situations, and this was not my first or even most difficult encounter. I do not know why this particular patient's distress triggered such an emotional response within me. I empathized with this ill and terrified teenager and felt the tension between trying to reassure her that she would be okay and advocating for a hospitalization. I know that I delivered on my promise to my patient and her mother and that the admission was short and uneventful. I had not ignored her wishes or her cries for help, and I had confirmed that she wanted to continue with treatment of both her leukemia and fungal disease. However, why did I continue to hear her voice in my head?

This pattern continued for days, even as I tried distracting myself with work, a tactic that usually works for me when dealing with unwanted emotions. Eventually, I realized this strategy was not working, and I knew this could not continue. Although I do not typically feel comfortable sharing my feelings, especially negative emotions, I eventually confided in a trusted mentor who is a pediatric intensive care unit attending with an interest in physician wellness, and I hoped she would be able to lend some much-needed advice. She immediately recognized that I was experiencing secondary traumatic stress (STS) and sent me online resources and podcasts to learn more about what I was going through. She encouraged me to speak with someone I trusted in my program about my experience and so I talked with an attending who was also my mentor. She listened attentively and shared her own similar stories and experiences. Being able to have my feelings validated and acknowledged in this way by people I trusted helped me to feel less hopeless and alone.

STS is being increasingly recognized in health care workers, especially in the wake of the COVID-19 pandemic. Also known as vicarious trauma, STS is related to post-traumatic stress disorder and in fact has overlapping symptoms of hypervigilance, avoidance, re-experiencing, mood disturbances, difficulty sleeping, and difficulty concentrating.

Although STS can contribute to burn out, it is a distinct problem as it occurs when a person hears and responds to the trauma of another (secondary trauma) instead of their own personal trauma. STS can be triggered by hearing about the traumatic experience of a patient. In my case, hearing my patient's own duress triggered personal feelings of stress. Risk factors for STS include having a high level of empathy, the dose of exposure, isolation, less experience, younger age, and sex (more common in females). Importantly, even single events can trigger STS.

The most important step in dealing with STS is recognizing the symptoms and knowing when to seek help. I was lucky that confiding in mentors and discussing my feelings with them helped my emotional healing, but it is not uncommon to need professional mental health help. The National Child Traumatic Stress Network posted a fact sheet to allow physicians to recognize STS in providers caring for children with trauma. Similarly, the American Academy of Pediatrics (AAP) published a health and wellness article in the AAP News discussing tips for providers. There are also now a variety of podcasts discussing the issue for those who wish to learn more.

I no longer hear that crying voice, but I know that I am certainly at risk for redeveloping STS. This experience, while distressing, did provide a valuable lesson about the importance of mentorship and communication. The act of sharing what I was going through and being lucky enough to have two trusted mentors not only recognize and validate my emotions but also guide me and remain available when I needed encouragement was enormously valuable. As someone who does not like to express any form of perceived vulnerability, something I imagine is common in many physicians; it felt unexpectedly

freeing to unburden myself. Resilience and tenacity have historically been touted as necessary personality traits in our profession, but vulnerability and sensitivity are just as important. Although these traits are not mutually exclusive, this experience has helped me embrace my vulnerable side. Although the culture of medicine does not always recognize the need for vulnerability, in my case, acknowledging these feelings has been emotionally healing and has deepened my compassion for my patients. I am so grateful for having received support from mentors who understand the need for balancing hard work and wellness, something I hope to do for others as I advance my career.

Dr. Lidia Schapira: Welcome to JCO's Cancer Stories: The Art of Oncology brought to you by ASCO podcasts, which offers a range of educational and scientific content and enriching insight into the world of cancer care. You can find all of the shows, including this one, at podcast.asco.org.

I'm your host, Lidia Schapira, Associate Editor for Art of Oncology and Professor of Medicine at Stanford. With me today is Dr. Aarti Kamat, Pediatric Oncology Fellow at CS Mott Children's Hospital at the University of Michigan. We will be discussing her Art of Oncology article, 'The Side Effects of Caring'.

At the time of this recording, our guest has no disclosures.

Aarti, welcome to our podcast.

Dr. Aarti Kamat: Thank you so much for having me.

Dr. Lidia Schapira: It's a pleasure. Tell us a little bit about your fellowship experience and storytelling. Do you read stories? Do you tell stories? How do you think about storytelling?

Dr. Aarti Kamat: I've always really loved storytelling. When I was a little girl, I thought I was going to be a writer when I grew up. So it's always just kind of been a part of me. I do love reading. My friends and I, to stay close during the pandemic, have actually done virtual book clubs where we read out loud to each other. So that's been a good way to stay connected with people and also to read and hear some good stories. So that's just always been a part of me and helps me relax.

Dr. Lidia Schapira: Can you share with our listeners some of the books that you've read recently that you would recommend to others?

Dr. Aarti Kamat: Sure. I've been on a little bit of a Jane Austen kick recently. She's one of my favorites. So I always turn to her when I need something fun and something for my downtime. So we just finished Pride and Prejudice and just are starting Emma now.

Dr. Lidia Schapira: Do you have a book club with some of your fellow fellows or some of your coworkers?

Dr. Aarti Kamat: Not with my fellows, no. I do have one with my co-residents, so people I've worked with in the past.

Dr. Lidia Schapira: So through this love of reading and stories, you also talk about a love of writing. Has writing been a part of your general sort of self-care portfolio, so to speak, as you tackle these very difficult years of training?

Dr. Aarti Kamat: It definitely has both through journaling and through just writing silly fiction stories. It definitely helps me. If I need to get out my emotions, I can write things about myself. Otherwise, I like to write stories to entertain other people.

Dr. Lidia Schapira: So let's talk a little bit about the essay that you sent and we've published in Journal of Clinical Oncology, which uses a clinical vignette as a way of introducing a very difficult topic, one that clearly shows in your narrative that you're very self-aware, but also where you share with the readers, a very particular vulnerability and a very difficult episode. Can you tell our listeners a little bit about how you live through these moments and how you are dealing with the trauma?

Dr. Aarti Kamat: Sure. It's definitely hard to live with moments like this, particularly in a field like Ped Onc. I'm very lucky to have a group of supporters who are both willing and able to listen to me when I am not able to handle something myself, both family and friends and coworkers. I have very experienced mentors who have gone through similar feelings and difficult situations, were always there to guide me. So I've been very lucky in that sense.

Dr. Lidia Schapira: Let's talk a little bit about the role of mentors in fellowship training. You talk about a patient triggering some trauma in yourself that you couldn't get away from that you realized was really interfering with your ability to function, if I understood your essay correctly. And you immediately found two mentors, who took you under their wing, and helped you. Tell us a little bit about this, untangle the process for us, recognizing the traumas, knowing where to turn for help, and then accepting the help.

Dr. Aarti Kamat: It took me a little bit to fully recognize and give in to the fact that I needed help and that I was struggling, I knew, obviously, that I wasn't feeling myself and was having these symptoms that were unpleasant. But I think, like a lot of us do, just try to initially ignore them. And that, obviously, was not working.

The one mentor, who I have always turned to who I know and has helped me through things like this in the past, I actually connected with during residency at the start of the pandemic. My program was very supportive and set up support groups, basically, for all of the residents to have one attending oversee. And she was the one who was assigned to me, and we just clicked and have stayed connected. And she's really helped guide me through fellowship and through the tough situations I've been having. So I knew I could count on her and turn to her for advice.

And then in my own fellowship, I'm very close with my research mentor, and she, similarly, has guided me through fellowship. So I knew that I could already inherently trust these people. So it was very easy to turn to them once I decided that that was something I needed to do.

Dr. Lidia Schapira: In your essay, you reflect a little on the culture of medicine. And, you know, you and I are not of the same generation. So I certainly remember during my training that you had to have sort of a hearty disposition, and it was all about tenacity and resilience and focus. And you talk a little bit in your essay about something that I think is so important for our readers to reflect on and hear, and that is that vulnerability and sensibility are just as important a trait of a good oncologist, pediatric, or adult. Tell us a little bit about how you discovered that.

Dr. Aarti Kamat: I think it really, I discovered it since being tenacious and closed off obviously wasn't working for me. I think that culture is certainly still there, and that's what I was operating under that I needed to be strong and emotionless and not let these things get to me. Clearly that did not work and was having a negative impact on my training. So it was definitely difficult. But I realized opening up and having that vulnerable and sensitive side was important. And we deal with difficult things, our patients have a lot of difficult emotions. So kind of being aware of our own emotions can help us connect with our patients as well.

Dr. Lidia Schapira: Tell me a little bit more about what you mean by embracing your vulnerable side.

Dr. Aarti Kamat: I think just allowing myself to feel that vulnerability and not be ashamed or feel like there's something wrong with me or that I'm not strong enough, but rather that this is just an inherent part of me and everyone and something that I need to feel.

Dr. Lidia Schapira: And let's take it a step further. And let me just say that I admire your courage for sharing your vulnerability with the community of oncology readers of JCO. What made you send this essay to us? And what drove you to put this issue of traumatic stress to the front and forward for our community of readers?

Dr. Aarti Kamat: Sure. So I had actually initially just written this as a reflection piece for myself, kind of like I do, like I mentioned earlier, I do enjoy journaling and writing when I need to process something. So it was just something I had written for myself to try and just another step in the healing process. And I did share it with my mentors who then encouraged me to reach out and possibly get this published, since it is something that affects not only me. It could potentially be helpful for others.

Dr. Lidia Schapira: So Aarti, let me ask you a relatively trick question here, and that is, if you were reading this as a Program Director for a Pediatric Oncology Fellowship Program, what would you do? What is the message that you would take home, and what changes would you make in your own program?

Dr. Aarti Kamat: I think I would reflect on my program and see, are there supports in place for my trainees who could potentially be going through a similar experience? Is there anything that we can be doing more as a program to support trainees or not even just trainees, but anyone working in the field and really just reflect and evaluate on that?

Dr. Lidia Schapira: Let's take that and think about that together a little bit more. What kind of resources or sort of wellness interventions do you think help? What have you heard from others and what has been successful for you and your fellow fellows?

Dr. Aarti Kamat: So I think trying to destigmatize needing to reach out for help. So having whether that's a therapist, psychologist, psychiatrist. We do have a very good program where I am where you can just reach out, and the program helps set you up with a therapist, at least temporarily, to help work through any potential feelings you're having. They really encourage us to make time for that. I think just making it easy to find people, like a mentor or an attending to reach out to is also really important, if, you know, the professional route is not the route you want to take. So just promoting a culture of openness with people who are guiding you, not only in your career, but also in your emotional development.

Dr. Lidia Schapira: So yes, I fully agree with you that creating a compassionate culture and compassion begins with self. So helping people to understand that as well is incredibly important. And one of the things I think that probably keeps you going back to work and me going back to work is that we also find the work we do very meaningful. Can you talk a little bit about the joys of practice for you?

Dr. Aarti Kamat: Sure. I mean, I love my patients. I love interacting with them and getting to know each of their unique personalities and their likes and dislikes and getting to know their whole families. And really developing that relationship is very important to me and very special to me. And it's a very, I think, privileged relationship.

Dr. Lidia Schapira: So what are some of the lighter moments at work both in conversation with some of your patients or with your coworkers, or even in your fictionalized writing, that help you feel that your emotional reserve tank is full?

Dr. Aarti Kamat: So I love just having fun with my patients. I always make sure that at our visits, we're talking about not only the medical things, but any fun things they've done in their life, or what they've done since the last time I've seen them. I make sure I know their favorite either princess or superhero, whichever they prefer. And I like to include that when I'm talking about them with other people. The same thing with my coworkers. We're all very close. And we love laughing and joking with each other. And we really love ordering cookies and having those in clinic. So that helps the day get by as well.

Dr. Lidia Schapira: And I'm wondering, do you ever read stories to your patients, to your little ones?

Dr. Aarti Kamat: I haven't. But now I think I should start.

Dr. Lidia Schapira: I think you should too. I have found it so interesting with so many of my patients, adult patients over time. I know who the readers are, I know what they like to read. And often that is the best icebreaker and the best way to connect during a visit even if the news we then have to tackle is not the brightest. So maybe you can try that and then write to us and tell us how it worked.

Dr. Aarti Kamat: I will definitely try that. I love that.

Dr. Lidia Schapira: All right. Well, it's been lovely talking with you, Aarti. Again, I thank you for sharing your vulnerability and helping us really understand how important this topic of secondary traumatic stress is for trainees. And I hope that our listeners and readers will take some good ideas home to make their programs even stronger.

Dr. Aarti Kamat: Thank you.

Dr. Lidia Schapira: Until next time, thank you for listening to JCO's Cancer Stories: The Art of Oncology. Don't forget to give us a rating or review wherever you listen. Be sure to subscribe so you never miss an episode. JCO Cancer Stories: The Art of Oncology is just one of ASCO's many podcasts. You can find all of the shows at podcast.asco.org.

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Guest Bio

Dr. Aarti Kamat is a pediatric hematology fellow at CS Mott Children's Hospital/University of Michigan.