In this episode of the ASCO Education Podcast, moderator Todd Pickard, MMSc, PA-C (MD Anderson Cancer Center) speaks 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: 6/16/2021
SPEAKER 1: 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.
SPEAKER 2: This is the first of a two-part episode on burnout in oncology. Stay tuned for part two of this conversation launching June 30, 2021.
TODD PICKARD: Hello, and welcome to ASCO's podcast episode focused on burnout in oncology. The prevalence of burnout among oncologists and other health care providers that care for oncology patients has been increasing in recent years, bringing along serious implications for personal well-being and professional satisfaction. My name is Todd Pickard. I'm an oncology PA at the University of Texas MD Anderson Cancer Center.
I'm pleased to introduce our three guest speakers today. 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 MacFarland, 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. Many oncologists around the world are struggling with burnout, but the topic is rarely openly discussed. We are excited to launch a discussion of causes and signs of burnout, as well as proven tools for the prevention of burnout that our listeners may apply in their own daily lives.
Welcome, all. I look forward to this interesting conversation today. Dr. Lavasani, can you tell us about your personal experience with burnout during your training and professional life? And then, how has the pandemic affected your experience of burnout?
SAYEH LAVASANI: Sure. First, I want to thank you for having me on this podcast. I noticed the symptoms of burnout when I was an internal medicine resident and had to do 30-hour shifts covering the ER, admissions, the internal medicine service, code blues in hospital, et cetera. It was a challenging time. I had a young child and [INAUDIBLE].
I would try to relax and meditate. And the peer support at that time was critical. All residents were very close to each other, which, I believe, can be the best strategy to overcome burnout during training. When I was going through my fellowship, things were definitely better and my calls were all home calls. And then I started to work as an attending.
Initially, I was under the impression that things would be easier, but I realized that my job is still very stressful but in different ways. I'm fully responsible for my patients and treatment decisions I make for them. Patients and their families are under tremendous amount of stress. We need to provide them with support and give them the strength to help them to go through treatment.
I felt multiple times that this is overwhelming for my health and well-being. I experienced burnout as a [INAUDIBLE] oncologist when I was in the process of moving to my current position, which required moving from East Coast to West Coast, moving and settling in there. Very stressful.
And then, this month actually marked the one-year anniversary of the start of the COVID-19 pandemic and the subsequent restrictions and lockdowns. It was an exhausting and challenging year for everyone, especially the health care community having countless number of meetings, integrating telehealth into our practices, fear of contracting COVID and spreading it to our families.
When I look back at this past year I have experienced fear, disappointment, but at the same time resilience and hope. I feel that like I learned a lot. We learned how to fight a pandemic. I personally learned to appreciate my health and time with family. I learned how to use small things during my day to cope with stress better. This has been my experience so far.
TODD PICKARD: Thank you for sharing that. COVID-19 has definitely added to the stress and burnout that many of us face. So thank you. It's a very common experience for many of us. Dr. MacFarland, would you like to share your personal experience with burnout? And has your approach to preventing or dealing with burnout changed over the course of your career? And if so, what's working well for you?
DANIEL MACFARLAND: Yes, thank you very much. I am delighted and honored to be here with everyone today and to share my story and our mutual interest in burnout and hopefully help some people along the way. Being that I had trained in two disciplines, medicine and psychiatry, I became very interested in burnout mostly as a result of having undergone supervision in psychiatry.
And then similarly to what Dr. Lavasani was saying, seeing the intense training conditions of the residents actually, once I had become a fellow, and it made me think back to a lot of the principles that I had learned undergoing supervision in psychiatry, meeting with the psychoanalysts. At that time, I was in Chicago, go down to Michigan Avenue and have these talks all about me, what my experience was in dealing with patients and life and the things that would trigger emotion for me, et cetera.
And I really felt like, I wish everyone could have that experience. And it almost made me sad or angry that people didn't and-- because once I became a fellow I saw that the residents actually were dealing with the sickest patients on the wards, talking to families, breaking bad news, and the look in their eyes.
Maybe my residency was rather cushy, I don't know. It was a little bit more intense where I trained for oncology fellowship. So I had started a program of research there to look at the empathy of resilience and distress. And I think stemming from that I got interested in burnout because there are these conceptual ideas that are all overlapping.
And, for me, it started from this idea of, how does the patient environment affect the clinician? And, thankfully, we're at a point where we-- you said at the beginning that we're not talking about burnout, but we are talking about burnout. We're talking about it right now. And the conversations are ongoing, are increasing, becoming more nuanced, in depth. And it's actually a really exciting time.
And not that long ago this was off limits, to really explore this area. And I think it's exciting and I think there's definitely hope. In my research, and I mentioned this book that we have coming out, et cetera, when you look back these things are not new, in a sense. There's always been this underbelly of medicine.
And the stoicism that was pretty much the only kind of working way to move through it, like sort of put up or shut up, frankly, which didn't work for a lot of people, and now we have an opportunity to make it better. And so it's so exciting.
So in terms of answering your question, it was really at the beginning an academic interest, I suppose. On a personal level, I will tell you that many of the things that you read about with burnout I've certainly experienced in practice seeing a lot of patients, that feeling of cynicism, this isn't working, losing the motivation, this is somehow losing the meaning, which is distressing.
Certainly cases of moral distress are challenging and you can bring it home. And even as a psychiatrist where you're trained not to do that, it happens. And we see things in oncology that they don't see as much in psychiatry. So how do you figure that out with the help of our palliative care colleagues, et cetera, is really important.
I noticed when I started practicing, for example, and it was a very busy practice at first, that I would use humor in a way that wasn't normal for me. I'm a somewhat funny guy, I suppose, but it was a little too much. And I knew that. One day I sat down, I said, this isn't me. Nothing atrocious. It happened. I don't know. Maybe I turned someone off. I don't know.
But it was this little light bulb in my head like, something is different. And I just thought, OK, of course. I mean, I'm the attending now, I'm seeing-- these are my decisions, this is weighty, heavy stuff, a lot of patients are not doing well. Many patients were doing well, which is great. But you see what I'm saying. So, wow, it happens. It happens to all of us. And, yeah, that was the biggest thing.
The other thing, having different, disparate interests has been challenging. A lot of what burnout stems from are systemic issues, are personal issues. How do we interpolate ourselves into the systems in which we work? Having interests in medicine and psychiatry, that's not easy. And so I've had to step back, reflect, take some life changes here and there, which I think, for the most part, has actually been quite beneficial.
So you asked, what are the things that I'm doing to help with burnout? Those are a couple. I would say the last thing, we're always told to eat well, do yoga, exercise. I do feel like I understand why we need to do that a little bit more, and that's what's helpful about learning about burnout because some of these-- you get burnt out learning about all the things you're supposed to do for burnout.
But if you understand the reasons why, and we'll probably talk about the data a little bit later, it's really helpful. So, I'd say a new approach to my personal burnout prevention regimen.
TODD PICKARD: I agree. I am encouraged by the fact that we're having more of these conversations. And our training is really an intense, intense time. I wish 25 years ago when I went through my training that it was encouraged to talk about burnout, because back then it was not. So you simply suffered in silence, put up, shut up, keep coming, and do what needs to be done.
So I'm very encouraged and grateful that we're having this conversation. We've talked a lot about burnout, but, Dr. Hlubocky, how is burnout defined? Many people, we all think what it is, but help us. What's the definition?
FAY HLUBOCKY: Oh, thank you. It's such an honor and a pleasure to be with my esteemed panelists here, and especially with all of you ASCO members to talk about your well-being. That is our priority at ASCO.
So burnout actually is an empirically driven phenomenon and it's been formally defined recently by the World Health Organization as an occupationally related syndrome that results from chronic workplace stress that hasn't been successfully managed. And there are three dimensions, or three signs, that are apparent.
It's a feeling of physical and emotional exhaustion, it's a feeling of cynicism and pessimism, and a decrease in professional efficacy. The clinician feels like they're not as efficient as they should be. Now this is the hard-working physician. It actually starts with several stages. The phenomenon is actually not new.
It was first described by Herbert Freudenberger, a psychologist in the 1970s, who noticed his colleagues on the inpatient mental health wards going through this phenomenon, this state of exhaustion and cynicism and reduced professional fulfillment and efficacy. And it's been done, well described now in the research by industrial organizational psychologists, like Christina Maslach, and more formally driven with empirical research and instruments that have been developed.
And then now in the clinical setting, in specifically oncology, we have a lot to thank Dr. Tait Shanafelt because he was probably one of the first ones to really describe it in oncology and in oncology physicians as to what-- so it certainly is not new. It's not just a bad day. It's not just being stressed out. This is a chronic, insidious process that we really have to prepare clinicians for, whether they're junior clinicians, to say this is going to happen, to be prepared for it.
And I really appreciate Dr. MacFarland's talk about psychiatry and psychology. We are almost a little bit more prepared for that. I think a lot of our supervisors tell us, you better watch out, you're going to be dealing with a lot of sick patients that are undergoing a great deal of suffering. Both he and I are in psycho-oncology so we work with the cancer patient and the mental health aspect as well.
So there was always this kind of supervision, making sure that you were OK. And, unfortunately, I think the COVID pandemic has afforded us an opportunity to have an open discussion, to reduce the stigma around burnout, that this is simply OK. It is right to talk about your well-being, that it is important to talk about your well-being in the long run.
TODD PICKARD: That's really helpful. I'm also curious, we've also heard the term of moral distress. Dr. Hlubocky, Dr. MacFarland, how do you differentiate burnout from that concept of moral distress? How are they different? Are they interrelated? Are they completely independent?
FAY HLUBOCKY: So I'll take the first stab, I guess. So actually, the research, it says that either moral distress precedes burnout or that they can co-occur. It depends on what literature you're looking at. So we're all distressed. The individual is in an environment where they know what is the moral action, the right thing to do, but because of the environmental constraints around they are unable to perform that duty.
And certainly, if there is an extended period of moral distress, certainly that can lead or be correlated to burnout. And the research is very clear. There have been some initial research and hematologic malignancies we've seen that Dr. Shanafelt was a part of. So both very important.
And especially you being an ethicist, it's incredibly important for us to recognize that that phenomenon can co-occur and actually even precede burnout. So as a community, we have a responsibility to recognize the ethical implications that burnout really does bring. Daniel, I'm curious as to what's your perspective.
DANIEL MACFARLAND: Yeah, great. I agree completely. I generally would look at it as burnout's a broader umbrella term, and that moral distress has both moral and distress-- moral implications of certain situations. The ways in which they're similar, a lot of the moral distress, as Fay was saying, come from being in a position of where your power is undermined or your autonomy to make decisions is undermined.
And obviously that is tough across the board, causes distress and even-- in terms of health inequities, you can look at how much locus of control you have, predicts your health. They go hand in hand. The other thing about the moral distress is when you're making the decisions you're less likely to be distressed about than when it's other people's decision.
So a lot of this actually comes out of the nursing literature about moral distress. But at the same time, there's the idea of moral success and moral climate. And so all things moral. So it's, again-- there are a lot of ethical implications to burnout, but it's more that burnout exists, the implications of burnout leading to worse patient care, worse quality of life, and all those other bad things.
But this is really about specific situations. And as it happens with, I think, ethical situations, the more that they're discussed, brought up, different perspectives are evaluated, the moral distress can recede. So the solutions are different. That's the solution for moral distress. And for burnout it's a little bit more amorphous. That may not be exactly what you would need if you were burnt out.
TODD PICKARD: Yeah, that's really interesting because I can't think of anything that would add more to my sense of burnout than knowing the right thing to do and feeling disenfranchised from doing that. That would be really difficult and would really cause additional stress and anxiety.
And so I can see how they're related. But, Dr. MacFarland, how do you know when burnout's starting? What are the signs? What are the symptoms? And then what happens if you don't address your burnout?
DANIEL MACFARLAND: Great questions. I think we have seen burnout in other people, and it may be easier to recognize the burnout in others than it is in ourselves. It goes without saying. I would be most inclined to pay attention to those subtle, automatic thoughts, if you will, that start-- as I was describing earlier, that's really the beginning of it.
And looking at variations of the sort of pattern of yourself, and-- I mean, the definition of burnout is emotional exhaustion, cynicism, depersonalization, this idea of personal accomplishment. But all of that is vague. In any given day you could have a little of this, a little of that, that kind of stuff. There is a general barometer, I suppose.
And I think this is one of the challenges of working with burnout is it's not going to get to zero. Where is that level that's good enough? It's hard to say. So in terms of identifying when you're having burnout, I think even, as I mentioned, sort of tongue in cheek, but even talking to colleagues, having that conversation about it is, how do you think I'm doing? I don't know. That might be a little too much.
But looking a little outside yourself, so look at your patterns, like, well, why am I showing up to work 20 minutes late every day, what's going on? Trying to take a look at something a little deeper to those behaviors. And I think it's an iterative process, in that regard. Maybe change one thing here, one thing there.
And so to get-- there was a second part to your question. The first was about signs and symptoms of burnout, and the second part was-- what was it exactly, Todd?
TODD PICKARD: What happens when you've got burnout and you don't do anything about it?
DANIEL MACFARLAND: Oh, boy. OK. Great question. If you were to ask me the same question about depression I would tell you that the general course of depression is nine months, hauling through it for nine months, don't do any therapy, don't take any medications, you've got about a year of suffering. I don't know that that's true with burnout.
I think burnout really is a relational concept between a worker and the workplace. And that's a way that it's different from depression, because symptom-wise they can look very similar. So the other thing would be all of the bad consequences of other entities that are associated with burnout, namely depression, anxiety. We're talking about issues with relationships, that these are your crucial support systems.
We're talking about your job, your work, your calling in life being compromised. And as has been alluded to, these symptoms can start early in one's career, even in training. And that's why they are so important to address, because it's a time when we want to be putting our best foot forward and burnout doesn't allow for that to happen.
So the consequences are myriad. It's you name it. Almost anything bad. Right? That's the short answer.
TODD PICKARD: I really like, and it resonated with me, when you mentioned using a trusted individual as a barometer to check yourself. But it also seems that having that trusted person that you could even talk about it with might be a way of preventing or supporting or addressing burnout. So I really like that idea of somebody that you can trust and check in with.
So, Dr. Hlubocky, how does this show up at work? What are those work-related and personal risk factors that can make us really susceptible to burnout and depression? How does our practice environment, what's its role and our risk for burnout?
FAY HLUBOCKY: Yeah. Well, first I'll speak a little bit historically what research has identified as what are some of the individual and the organizational risk factors. So originally and historically a lot of research and studies have confirmed that it was the single, the unmarried, mostly female, junior clinician, the very type-A personality, very dedicated to one's job, not knowing when to set boundaries, very much dedicated to patient care, potentially the community oncologist, for example, that was the person most prone and at risk for burnout.
But also, now we have identified that it affects actually everybody at every point in time in their career. So although females may present with exhaustion, males present with a great deal of cynicism. So those kind of earlier research has really changed. And the COVID pandemic, in particular, we'll have to see years from now, but the research that's in its infancy it says that the sense of loneliness, the fact that the oncologist really misses their colleagues, their patients, even the family members, that isolation that they have had to undergo as a result of caring for potentially COVID-positive patients, that is quite challenging individually.
But more so, we really need to focus on the organizational risk factors. And historically it's been those, of course, long hours, working with seriously ill patients, increase in administration time, the limited autonomy and independence and lack of control over the daily responsibilities that a lot of clinicians-- and the increase in the EMR, that really takes away from that clinical encounter.
Why did so many of us become clinicians? Because we loved our interactions with patients. But yet, now we're more beholden to the EMR, into the computer, and doing all this administrative work. So certainly research has shown that almost more now recently, within even the past five years, that the organization, and that environment, that culture, it's important to change. It's important.
Burnout is reflective of the practice help. You won't have a burnout physician if the practice is supportive in a way. And that's not to beat up at all on administration or leadership. I work with tons of leaders that want to help their colleagues, they just don't know how to. So it's important to encourage both the individual clinician as well as for the system to change.
So important to optimize our clinical environment, really to change that culture, the infrastructure, the resources, the EHR. Scribes, for example, have been used in some practices as a support and really reducing the stigma associated with burnout and any mental health issues that may arise as a result of unaddressed burnout. So many colleagues are frightened to report that they're having an issue, that they might be judged, that they have to report it to their state boards. We really, really have to come together as a community to optimize oncology care and optimize well-being for the oncology clinician.
TODD PICKARD: Absolutely. This is a great tie-in to the environment of care that we work in, the systems that we work in. So I'm very curious, Dr. Lavasani, are there any burnout prevention strategies that your institution, or your practice, is using?
SAYEH LAVASANI: Yes. We have a well-being committee at my practice that meets once a month. We have access to an external psychiatrist, counselor, and also an internal psychiatrist. She also sits on the well-being committee. All physicians that are multiple activities that we can attend to like [INAUDIBLE] parties.
And there's also Zumba and yoga classes over Zoom that, twice a week, that we can participate. And there are also support sessions using mindfulness to recognize, reduce stress. And we have also annual medical staff survey about burnout and stress.
TODD PICKARD: It's great to hear that your practice and institution is taking some steps to support their providers. That's great. Well this has been a terrific conversation. I really enjoyed it. I feel that I've learned a lot from all of you. So thank you, Dr. Lavasani. Thank you, Dr. Hlubocky. Thank you, Dr. MacFarland, for your engagement and conversation today.
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