COMMENTARY

'Remember Why We Went Into This': Balancing the Dark Days in Oncology

Don S. Dizon, MD; Susana M. Campos, MD, MPH

Disclosures

July 02, 2019

This transcript has been edited for clarity.

Don S. Dizon, MD: Hi. I'm Don Dizon, professor of medicine at Brown University and director of women's cancers at Lifespan Cancer Institute. Joining me today is Dr Susana Campos, assistant professor at Harvard Medical School and Dana-Farber Cancer Institute. Welcome to Medscape Oncology Insights.

I thought that rather than talking about the science of oncology, it would be interesting to talk about work-life balance. We have been in practice for quite a long time and we've seen differences in how institutions value our roles as clinicians as well as the contribution of our research. It seems that while the demands increase almost every year, the struggle to maintain yourself clinically becomes overpowering.

You are a successful, well-known, gynecologic oncology expert, and I thought it would be interesting to know your take on how medicine has evolved and how you have seen the pressures affect the colleagues who refer to you.

Challenges of Work-Life Balance in Oncology

Susana M. Campos, MD, MPH: Medicine has become more complex. When we trained 100 years ago, things were a bit simpler. We knew cytotoxic chemotherapy. But now we need to have a tremendous knowledge of genetic makeup of the disease, of the genomic aberrations, and what those genomic aberrations may do.

Patients are living longer, which is wonderful. But with that comes a complexity of patients who come to you after having already undergone multiple lines of therapy, asking once again, "What is the next step?" This takes time in the clinic. It takes time to see the patient and absorb the patient's needs. There is the added complexity of the patient's family. You have to do all the reading that guides you. You then interact with many different disciplines; we work as a village.

If you run a clinic of 30 patients between you and your nurse practitioner, that is a lot of work, time, and effort. But we all love doing this and it is what we want to do every day. It gives you a high. Still, you need to balance the weight of the clinical material that you have to address with the metrics that you have to meet. There has been a lot of discussion about burnout and depersonalization. As we experience more and more conflicts and more demands, and as medicine becomes more complex, we want to measure up. We need to find a way to balance that.

Dizon: Throughout the years, how have you seen institutions respond to this? The metrics that define a successful practice shift, so there is no national standardization. When I started at Memorial Sloan Kettering as a new attending, it was very clear what the expectation was, and if you met it you had no pressure to go beyond that expectation. They still allowed that time for academic pursuits and to open clinical trials. They allowed you to go to meetings and they supported you financially for a career in academics. The trouble I see as time has passed and medicine has become more complicated is that demand on clinical productivity has increased, but not as much on the academic side. What is your take on this?

Campos: I think it's true. We often spend some time talking among ourselves that we do more clicking than talking. It's a bit distressful when you are always on the computer and not really talking to the patient; you try to make amends for that when you are in the rooms. Every institution tries to deal with this in a different way. I'm perfectly capable of holding a load but I like an efficient clinic. Every little minute counts. I would rather have a minute spent with the patient than me circulating the neighborhood just to find an extra piece of paper.

There has been dialogue in our institution about how to make a clinic more efficient and how to utilize our nurse practitioners so they can see some patients and you can see some patients—that hybrid of clinical practice is much more powerful. Clinically, our mid-level providers have so much more to give than perhaps we allow them to give. [Using mid-level providers] also creates some time that you can share with the patient and maybe put your effort into more of a complex nature or engage in a clinical trial and so forth.

Some institutions have looked at wellness centers for ways to build resilience and work-life balance. It's a wonderful discussion, but at the end of the day, you have to look at what the culprit is—it can't be a Band-Aid to what we have now. It has to change the culture to where we do have more time with patients.

What are relative value unit requirements? What are the metrics that every department wants? How do we balance that in a clinic that is growing exponentially every day? I'm not so sure there is an answer to these questions right now.

Mentoring Those in Early Practice

Dizon: That is the dilemma. Both of us have seen folks enter our departments, and some have stayed but many have not. What has been the experience of those folks whom you mentor as they start clinical practice with a broader vision of one day running a cancer center or running their own division?

Campos: You need to have an honest dialogue with them. You have to be a good clinician, but at the same time you need to have some time to yourself so that you can become a good clinician. We often leave reading to the evenings or the weekends. People have to be knowledgeable. And you have to keep an open vision, too, to know how to make a clinic run smoothly. What are the ins and what are the outs? It sometimes takes very little effort to be incredibly efficient and get some other things done. [You need to have] an honest dialogue about how to utilize your time most appropriately, how to not get bogged down with certain little things, and how to restructure your time so that you will succeed and move forward instead of running in the same place.

It was emotionally exhausting, and I think it almost broke me, quite frankly.

Dizon: Do they ever comment on the emotional aspects of the job? [I remember when] I first was an attending. It seems like it's the first-year curse that you are going to see every young woman with cervical cancer and every woman who is pregnant when they found their ovarian cancer. Back in the day, they didn't live that long. And it seemed like when folks start not to do well, they don't do well in groups. And all of a sudden, this group of patients all start dying, one after the other. It was emotionally exhausting, and I think it almost broke me, quite frankly.

Campos: It is emotionally exhausting, and sometimes you see this so very often that you forget how it affects some of our young colleagues. It's okay to feel. I was once told by someone that when you stop feeling, it's time to get out. You should feel. You can't absorb every case. I always say to our fellows, "Was there anything you could have done that you didn't do, not to look back in terms of blame but as a reflection? You have succeeded. You've given this person the best quality of life that you could." We have to be mindful of how it affects ourselves, for that matter, and also our young fellows coming into the equation. They don't see this every single day. [They may need] to prepare for that both physically and emotionally.

Dizon: You raise a really good point that when you look back at a case, it is not to see where you went wrong but to reflect on the experience and what you could possibly gain from that experience. What are your tips in terms of dealing with the emotionality of a cancer practice?

Campos: We have to remember why we went into this. Enjoy and get to know your patients. Enjoy when the kids are going to college, when there is a special event in their life. And most importantly, listen to them. Even with all the next-generation sequencing and all the genomic profiling, it's very basic: Just listen and engage with them. Delight when they succeed and be sorrowful when they don't, because you are a human being. If they see that, they will understand who is on their side.

Dizon: I'm sure you've had this experience before. Sometimes I will see a patient with a fellow and I walk in and say, "How was your trip?" because I knew the patient went on a cruise. Or I'll say, "Your daughter got married last month. How was the wedding?" Fellows will come out and say, "How did you remember that?" Do you think that is a skill to be taught or something that you are born with?

Campos: It's probably a little bit of both; in some people it comes extremely easy. In many ways, knowing your patients becomes part of the fun of being a physician. It also can be taught. We can teach our fellows that it's okay to interact with our patients. They trust you, so when you do have to engage in a discussion that is not fun, they understand that you have their back. That is extremely important.

Dizon: I've taught my fellows that if something is happening in their patient's life, they should write themselves a note so when they open that chart, it's the first thing they see. If you can't remember or you are not sure, teach yourself to remember. Recognize what's important to your patient. If you have to write it down so you get that nudge, then [write it down].

Campos: Absolutely. It opens a door that will never be closed.

Dizon: Because cancer is becoming so precision-based and so genomic-based, are you concerned about the humanism in oncology?

Campos: Not really; I think that is very much intact. I only know this discipline, but it is a very humane discipline. You are not dealing with simple matters; you are dealing with things that are very challenging. Every day can be a very challenging task. I think it's now more complex behind the scenes. [Genomic testing] creates more stresses, but we've all had that patient with a mutation who responded beautifully, and that is a delight. You get a union of both. I don't think that because we're spending a lot of time on molecular and genomic aberrations that it subtracts from [humanism]. We are going to have to weave around it a little bit.

You have to have it to give.

Keeping Yourself 'Intact'

Dizon: I've known you for a very long time and I know that you are an exceptional clinician, so my final question is, how have you kept intact?

Campos: There are days when you are not intact. There are days when you are just simply very fatigued and you go home feeling a little dark. But there are days when you have this amazing response and you change people's lives, and it brings you up again. It's a balance.

One hundred years ago when I was a resident at Georgetown, I remember this one particular woman in her late 40s. I was an intern and I went to her hospital room one evening because I had to draw her blood. She was incredibly anxious. She had metastatic breast cancer in 1992, which was very different than it is today. She was not interested in me drawing her blood; she was interested in someone just sitting and talking to her. That day changed my career path because she just wanted somebody to listen to her.

It's very important when you go into this field that you want to give, but you have to have it to give. You have to have it to give. And it's quite important to protect yourself by having protected time, going on vacation, and turning the pager off. What a novelty!

Dizon: That is a really important life lesson, and I hope the audience hears it quite well. I love that: You have to want to give, but you have to have it to give. I think that's fantastic.

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