Oncologists commonly suffer “professional grief” when a patient dies — in fact, it is a “familiar, daily reality for the oncology clinician,” says one — but when it is also accompanied by a sense of emotional isolation, it can lead to reduced well-being and burnout.
The issue was discussed at a special session at the American Society of Clinical Oncology (ASCO) Annual Meeting, and several speakers offered solutions.
Laurie Jean Lyckholm, MD, professor, Hematology/Oncology, West Virginia University School of Medicine, Morgantown, polled the audience to ask how they deal with patient-related loss and grief.
The responses showed that 44.4% said they talk with their colleagues, 16.7% said they talk about it with family and friends, but 22.2% said that they simply move on to the next patient.
Lyckholm noted that there are positive and negative ways of dealing with grief.
One example of a positive way comes from an oncologist who attended one of her talks and shared with her how his practice deals with the issue.
“At the end of every fourth Friday, he closes his community practice office early and all the oncologists, everyone, stays for a while, and they have a list of the people who have died,” Lyckholm explained. As a group, they go through the list and reminisce about the patients who died, recalling funny incidents or things that person had said.
“I love this idea,” she said. “The most important thing is to commemorate that person.”
Amplified During Pandemic
Like many other issues, the problem of how to deal with “professional grief” was amplified during the COVID-19 pandemic. Many people were unable to see their dying relatives, because of the restricted access to sealed-off, dedicated COVID-19 units. One oncologist who had developed a friendly relationship with a patient while treating them for cancer over several years was unable to visit the patient once they were ill with the disease, and was left to communicate via an iPad. “It was the only way I could say ‘goodbye’ before she died….It still haunts me today, 2 years later,” the clinician recalled.
This anecdote illustrates “disenfranchised grief,” which occurs when an individual experiences a “significant loss and the resultant grief is not openly acknowledged, socially validated, or publicly mourned,” Lyckholm explained.
If this goes unrecognized, it can lead to shame, guilt, and organizational mistrust, resulting in reduced well-being and clinician burnout, she warned.
The pandemic also had an impact on clinicians directly. Lyckholm quoted one nurse practitioner who talked about coming back to a new “lonely normal” when returning to a Veterans Affairs hospital.
“I am still getting used to calling colleagues, and paging colleagues, and realizing that they just aren’t there,” the nurse practitioner said. “They aren’t there because they either left or died. I just didn’t expect that.”
Lyckholm said, “I don’t think we can ever stop acknowledging COVID, because it just had such a terrible impact on all of us.”
Teamwork Intervention
The next speaker also polled the audience. Christopher Ryan Friese, PhD, RN, AOCN, Elizabeth Tone Hosmer Professor of Nursing, University of Michigan, Ann Abor, asked the audience what strategy they would prioritize to reduced burnout, from the perspective of the entire cancer care team.
The response indicated that many (43.6%) would like to see team-based grief and bereavement sessions, while 31.1% thought it best to tackle low-value administrative work.
Friese drew on a teamwork intervention that researchers at the Dana-Farber Cancer Institute, Boston, Massachusetts, with support from the National Cancer Institute, implemented to help identify opportunities to improve cancer care delivery services.
It began with a focus group of nurses who were invited to identify practice pain points, and then six 2-hour sessions with all members of the clinical team to identify and develop service expectations and commitments across the various roles.
After these sessions, the researchers saw a decrease in missing orders from 30% to 2%, while patient satisfaction increased from 93% to 97% as a result. Interestingly, there was also a reported rise in efficiency, practice quality and safety, and respectful professional behaviors.
The pilot was then rolled out across the whole institution, and Friese and colleagues also implemented a version of the program at their community medical oncology practice.
They had a huge response from patients and clinicians alike (with participation rates of 90% and 78%, respectively), and the survey results led to changes in workflow and the standardization of communications.
Importantly for Friese, the clinicians who took part wanted to repeat the survey to evaluate any practice changes, which was not part of the study protocol and had not been envisaged by the researchers.
So they developed a survey for clinicians, using as an inspiration the Choosing Wisely campaign by the American Board of Internal Medicine Foundation to identify the best treatments to improve patient outcomes and those to deprioritize.
They used the survey on 373 clinicians at the University of Michigan Health System, and found that “the number one thing was getting rid of the administrative work” — that it doesn’t have to be done specifically by physicians or other providers, but that other people can do it.
The second was time-consuming electronic health record tasks.
Both of these have since been the focus of an elimination and reduction process to give clinicians more time to do what matters most to them and their patients.
“We have the opportunity to do this in a different way,” Friese said, “and I think it’s a really powerful opportunity.
“We can retrofit the solution, which is the pizza parties, and the yoga apps, and the T-shirts…[or] we could actually redesign the work that we’re asking clinicians to do on a daily basis,” he commented.
“We could make the work easier to do so that you have more time with patients and less time with administrative work, and have more time to process grief, or to celebrate successes,” he concluded.
Tackling Burnout
The final speaker, Vicki A. Jackson, MD, MPH, chief of palliative care, Massachusetts General Hospital, emphasized that the recognition of grief by a cancer care provider is “imperative” for physician well-being, and pointed out that that interventions to help “do exist,” including ASCO’s SafeHaven collection of physician well-being resources.
Oncology inherently carries with it “threats” to well-being, including uncertainty and doubt, isolation, fears over one’s usefulness, exhaustion, the witnessing of suffering, and moral distress, she noted.
Things that are necessary for well-being, in contrast, include a sense of connection and community, having boundaries between work and personal life, self-awareness, compassion, and empowerment, among others.
Jackson believes that in the current era community building within oncology must be “intentional” and not just based around “water cooler moments,” as the sense of isolation experienced by clinicians is “not fluff; this is critical.”
Initiatives such as virtual happy hours and game nights may be helpful, she suggested.
A colleague of hers likes to send out the dad joke of the day, “which made everybody groan, but let me tell you, it changed the affective tone before they started seeing all these really hard, sad patients.”
Setting boundaries, which was the topic of another session at ASCO 2023, is also an important way to address the “emotionally powerful” work of oncology, Jackson commented.
She underlined the need to channel or be “fully present when you are in the room,” but emphasized the need to detach at the end of the day, commenting that “when you leave, you leave.”
No funding was declared. Friese reports relationships with Merck (Inst); NCCN/Pfizer (Inst); National Cancer Institute; Patient-Centered Outcomes Research Institute (PCORI); and Simms/Mann Foundation. No other speakers report relevant financial relationships.
American Society of Clinical Oncology 2023 Annual Meeting: Session: Addressing Grief, Burnout, and Well-Being in the Practice of Oncology. Presented June 5.
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