Burnout alert!
30 November 2008 11:12 PM
During my early years of practice I was totally unprepared for the world that I was eagerly looking forward to dwell in after training. The upsurge of scientific knowledge has changed the landscape of medicine, and the hapless clinician sometimes finds himself drowning in the overwhelming immensity of information that he has to cope with if only to keep himself up to date and offer the best possible therapeutic possibilities to his patients.
But beyond mere clinical competence, I realized that my training did not prepare me well for the equally crucial facet of doctoring as it failed to address the human and psychosocial aspects of caring for people with a disease as dreadful as cancer. I am grateful to my consultants who taught me the essential knowledge and aptitude to manage cancer. Evidence-based medicine with its emphases on unassailable research designs and protocols, on highly sophisticated machines and tests in the medical armamentarium, and on thorough analyses and peer reviews became our mantra, meant to convince patients and their families of gold standards and best clinical practice guidelines as well as to set the profession apart from mere quackery or folk remedies. Evidence-based medicine has become the benchmark by which doctors protect their patients and the profession from the immoderation of traditional healing practices and even “anecdotal” medicine.
Armed with the best training a doctor could possibly acquire, I went home eager and optimistic only to realize that even the most sophisticated targeted therapies and nanoparticle designer drugs were not enough to address the emotional needs of the patients and their families. Even the best and latest discoveries that conferences around the world have been enthusiastically talking about could not wholly assist the patients in accepting the truth about their diseases, in making rational choices on treatment and supportive care, and in adapting to the myriad spectra of signs and symptoms that breast cancer or leukemia or prostate cancer brings.
Dr. Lidia Schapira from the Beth Deaconess Medical Center in Brooklyn offers a solution that integrates the “disease model,” which embodies the medical diagnosis and the pathophysiologic mechanisms of the disease, with the “illness model,” which looks into the patient’s conceptual and experiential knowledge of cancer. She wrote “Training should be flexible and creative enough to allow us to weave there two perspectives into a unique narrative that completely captures the reality of each clinical encounter.”
Grief, futility, exhaustion, guilt and the existential aspects of being a doctor are harsh realities of practice that must be confronted by a medical oncologist. When I first dreamed of being a doctor, I pictured myself like I was Superman who is able to save the world from aliens and predators and resentful Lex Luthors, and even find time to rescue a hapless kitten up the tree. The road I’ve taken seems remotely detached from the picture-perfect reality TV fare especially when one thinks about the cold facts: that more than half of patients are usually seen in the terminal stage, that 43% of Filipinos die of cancer without medical attention, that one out of two Filipino cancer patients succumbs to the disease within a year, and that most Filipinos can hardly afford the basic treatment. In this setting, a medical oncologist is constantly besieged and sometimes crushed by tsunamis of bad news, untimely deaths, treatment failures and disease recurrence, patient suffering, medical futility and death.
Most people see doctors as caring, compassionate and honest professionals who are able to guide, educate and comfort them with their knowledge and training during the most trying times. Sometimes they forget that doctors are people too, given to their own flaws and prejudices, judgments and designs for self-preservation. Physicians as no less human than the average Joses and Marias, in fact many of them are drawn to the profession through their sensitivities to the needs and sufferings of others.
Unlike the other subspecialties like cardiology or pulmonary medicine, the care of cancer patients requires certain fortitude to get over the fact that patients will continue to die despite the best efforts and greatest intentions. Some of my mentors took this career path with a sense of optimism about the future and about the promise of medicine to alter the natural history of cancer from a debilitating and fatal illness into a controllable chronic disease for many patients. Most medical oncologists of my generation often view the subspecialty as an opportunity to look after the needs of people during periods of intense vulnerability.
While cancer doctors breeze through the day with unsullied dedication to the profession, they often have little time to debrief themselves, to process their own sorrow about a patient’s suffering and death. The next patient simply needs his time. Whatever time is left of him is appropriated for paperwork, guidelines, administrative matters and the fear of a litigious environment. Thus, personal unresolved emotions are shelved in favor of patient care and institutional demands. As in many of life’s invitations, these rain checks are bound to stack up, allowing these unresolved emotions to overflow. When compassion is exhausted and burnout is at work, the doctor becomes callous, distant and technical, and renders him ineffective.
Every oncologist must recognize these issues in order to achieve renewal and well-being. There are approaches through which doctors in danger of burnout could channel their emotions; journals speak about limiting workload, designing flexibility in scheduling, even developing coverage systems with colleagues. Other avenues include pursuing self-care activities, nurturing personal relationships, developing a life philosophy that promotes balance between personal and professional lives, and engaging in spiritual practices.
Over the years, I have learned to infuse my routines with generous doses of distractions, those activities unrelated to the practice of my profession that offer relief from the onslaught of grief, exhaustion, burnout and existentialism that I face daily. Mason Cooley, famous American aphorist, wrote about this once: “My mind is led astray by every faint rustle.” Talk about taking one’s mind off the niggling vexations of daily habits. I tried practice shooting once and realized that the sight, the nuzzle and the trigger should work in sync or one is bound to waste those blanks needlessly. Those rare times when I managed to hit the target occurred after I pictured this nephrologist’s mug staring at me from the bullseye. But then, that was an even more gratuitous misuse of blanks. So I moved on to other less frightening things that prevent one from recapturing a constant picture of her bloated visage. Sometimes, I take trips or photographs.
But I realized that I need not venture farther than my own office. I now find joy in every encounter with the patient and his family, realizing that each meeting shapes not only their lives but also mine. Each session has taught me that the fundamental tools in my trade are my senses: sight, hearing, touch. There are times when I am thankful to the late Dr. Alex Panuncialman, former dean of the Davao Medical School, for instilling in every medical student the value of fortitude, of looking beyond mere anatomy and physiology. With the most trivial things in life, he taught me how to look closely, to listen intently and to feel deeply, which are what he called the basic skills of a doctor.
In talking with my patients and their families I do not simply give medical options and technical expertise, but I also give of myself. These sessions that sometimes last for hours have a clever way of teaching me how to be truly human, how important human relationships are, and how powerful human connections can be.
