Burnout In Cancer Clinicians: The Demoralized Clinician; The Demoralized Institution

David W Kissane, MD Objectives 1. 2. 3. To understand the nature of burnout in oncology To understand factors in providers, patients, and the work environment protective and predictive of burnout To review self care principals and explore advocacy approaches when concern exists about burnout in colleagues or team members

When clinicians experience a progressive loss of energy, commitment and purpose in the care of their patients, leading to role dissatisfaction, exhaustion and negative attitudes towards patients, colleagues and self, burnout should be considered. Studies have repeatedly shown that up to 25% of oncology staff are at risk. Warning signs include low morale, loss of satisfaction, boredom, fatigue, insomnia, decreased empathy, relational difficulties and absenteeism. Maslach in studying burnout recognized that distancing processes which become habitual in the clinician reduce empathy and protect the clinician from emotional involvement and risk of exhaustion. So entrenched can these become that the well defended clinician lacks insight into this depersonalization process and continues without sensitivity to the patients needs. Burnout can certainly lead to established psychiatric disorders in practitioners, including depression, adjustment disorders and post-traumatic stress disorder. More commonly, the signs are subtle, with reduced idealism, negativity, loss of energy and a critical stance about others predominating. When this develops into negative attitudes towards patients, the danger exists that the demoralized clinician will deliver poor medical care. Conversations in the staff room that express disgust, pity and intolerance indeed a host of negative attitudes towards patients highlight the presence of burnout. Demoralization is contagious and easily transmitted from patient to family to staff to doctor to nurse. A demoralized multidisciplinary team ceases to see the point of continued care provision and transmits an attitude of hopelessness and helplessness to its patients. Training, skill development and communication are important counterpoints to such developments. Vulnerability factors include lack of supports, personal vulnerability towards depression and substance abuse, propensity to self medicate, high expectations and sometimes a compulsive need to care. Role strain inevitably emerges. When symptom management in the patient is difficult, toxicity occurs, interpersonal difficulties abound or the family in the background is dysfunctional, the setting is ripe to deteriorate and the patient can be readily blamed. Poor teamwork, rivalries, work overload and inadequate resourcing quickly confound these problems. Self-care is crucial. Holidays, interests outside of work, colleagues to debrief with and limiting workload realistically is vital. Variety in what one does is helpful. Most importantly, adequate education and skill development brings professionalism to the role, which needs to be constantly updated through conference attendance and continuing medical education. Openness with our colleagues and advocacy when concerns arise are leadership skills that sustain a healthy work environment. Team exercises help to not label any individual, yet can promote insight and improved care. Isolated, solo doctors may be especially vulnerable. Palliative care teams have made use of multidisciplinary support to sustain morale, brainstorm the management of difficult patients, debrief together and extend support beyond the narrow boundaries of the team. Finally, institutions have responsibilities to adequately resource, train, remunerate and support their staff. Effective communication and quality assurance processes sustain teamwork and productivity. Good staff morale is a marker of safe institutional processes; demoralized hospitals breed poor standards of care and disgruntled staff members who struggle to survive, let alone care.