Unique Emotional Challenges Faced by Oncologists

Roxanne Nelson, RN, BSN

July 04, 2019

CHICAGO — In a session about physician suicide, and the factors that contribute toward such a devastating event, one speaker highlighted the unique emotional challenges faced by oncologists in clinical practice.

On a daily basis, the oncologist walks into a room where a person is "suffering mightily."

"They do it over and over and over and get to know to their patients and families very well."

"The paradox of that is that we suffer when they suffer," said Bill Eley, MD MPH, executive associate dean at Emory University School of Medicine in Atlanta, Georgia, and a medical oncologist specializing in breast cancer.

"It is a distinctly human thing to do. It's distinctly Darwinian to avoid death. We are programmed…we are hardwired to avoid it."

"And yet, we as oncologists walk into these rooms every day and do our very best," he said.

The second dilemma for the oncologist is that the prescribed treatments can also cause a great deal of suffering.

Eley pointed to his own brother, who died 5 years ago from lung cancer, and who had received chemotherapy. "But as only my brother could say — 'this infusion center you have is an elegant torture chamber staffed by the kindest humans in the world.' "

The third issue in oncology is that relationships with patients have become much longer.  "We keep more people alive, thankfully, but it does increase the complexity of what we do," he said.

When an oncologist has developed these relationships, and then loses them, it causes sadness and suffering.

"I think these three things that are as close to unique for us as anything else — the amount of suffering we cause with treatment, death, and the results of a long-term, positive relationship, which just makes it all the more painful," Eley said.

Eley then quoted from the mystical writer Carlos Castaneda: "The trick is what one emphasizes. We either make ourselves miserable or we make ourselves strong. The amount of work is the same."

"I often tell people I'm the luckiest person in the world because I get to work with the people I get to work with. And I get to be with patients and their families through some of the most difficult times in their lives," he said.

Eley was speaking at a special session held during the recent annual meeting of the American Society of Clinical Oncology (ASCO). The session was titled, "Elephant in the Room: Addressing Depression and Suicide Among Oncology Providers."

One of the talks highlighted the pressures faced by students in medical school as well the intensification of these pressures when they become interns and in their first few years in the profession.

Eley commented that during medical school and residency, "it's almost as if we have recurrent posttraumatic stress disorder (PTSD) that is not treated."

"We see tragedy after tragedy. And we go see the next patient. And we go see the next patient. And there is very little attention to processing grief and sadness and suffering in our systems."

From his own experience with cancer patients, Eley said that he has learned bravery, gratitude, and has become wise. "I certainly became humble and want to live a life of learning to help others, and I think I've become inspired," he said.

He concluded by emphasizing that he doesn't think that "we can get there unless we fully engage with the suffering. And it's almost antithetical that to get through the suffering, we need to lean into it instead of protecting ourselves from it."

"Protecting ourselves is a way to shut down, become isolated, and all sorts of other things," Eley added. "We need to keep feeling. And we need to do that with each other."

Not a New Problem

Among the known factors that contribute to suicide among medical professionals, depression and burnout rank high on the list, commented another speaker, Michelle B. Riba, MD, from the University of Michigan Comprehensive Depression Center in Ann Arbor.

This is also not a new problem, she emphasized.

"The AMA consensus statement on physician well-being from 2003 concluded that the culture of medicine accords low priority to physician mental health despite evidence of untreated mood disorders and of suicide," she said.

Now, 16 years later, not much has changed. "There are many barriers to treatment in terms of discrimination and licensing, hospital privileges, and advancement," Riba pointed out.

Several studies have examined depression and suicide in the medical community. One is the Intern Health Study, a longitudinal study of depression among interns nationwide, which screened 740 medical interns in a range of specialties, at three month intervals during their first year as physicians (Arch Gen Psychiatry. 2010;67:557-565).

The researchers found that the rate of depression increased dramatically during internship, from 3.9% to 25.3%.

"It was sort of very cyclical," said Riba. "There was a direct association between the number of hours worked and the risk of depression."

"Within internship factors, a higher mean work hours score perceived not just real medical errors, but perceived errors in stressful life events," she said.

Barriers and Solutions

Another study looked at barriers to treatment for depression among interns. Participants reported that lack of time, preference for self-management, problems with access, stigma, concerns about cost, and a belief that treatment doesn't work were the top reasons for not seeking care. (J Grad Med Educ. 2010;2:210-214).

"We know in psychiatry that in terms of depression, the best and most optimal type of care usually is medication and a form of psychotherapy," Riba explained. "But only 6.7% of these interns were being treated with both therapies, 8.1% with therapy only, and none with medication only."

Of this group, 85.2% received no treatment at all, demonstrating that screening for depression "is just not going to be enough," Riba noted.

Since the original intern study was published in 2010, many more studies have been conducted, looking at not only depression, but also burnout and suicide in medical students, residents, and early career physicians.

One paper reported that of 381,614 residents in training during years 2000 through 2014, 324 physicians died during their residency; 220 men and 104 women ( Acad Med. 2017;92:976-983). "The leading causes, in general, for the residents were neoplastic disease followed by suicide and then accidents," Riba told attendees. "But for men, suicide was the leading cause. And for women, malignancies were the leading cause."

Death by suicide among residents was higher earlier in their training, Riba noted.

Overall, the suicide rate is about 1.4 times higher for male physicians and 2.2 higher for female physicians as compared with age-matched controls.

As for factors leading to suicide, Riba pointed out notable differences between physicians and the general population. Physicians are less likely to have experienced the death of family or friends, but more likely to have a job issue. There is a higher measurable level of use of benzodiazepines and barbiturates among physicians, a presence of known mental illness, and physicians tend to be older. "And there are major barriers to help seeking diagnosis and treatment due to stigma," she noted.

Finding solutions can be complex and there are "now lots of groups trying to figure out how to provide care to physicians in training, medical students, and to physicians in general, without having to go to a mental health professional's office," Riba said.

Web-based cognitive behavioral therapy interventions are one example that have shown efficacy. At her institution, the University of Michigan, she explained that they are using web-based and group based formats to help medical students and residents get appropriate care.

"We have to start changing the curriculum and provide emotional and social support from the very beginning of training to medical students, residents, and fellows, and early career physicians," Riba concluded.

Physician Heal Thyself

What can be done about physician depression, burnout, and suicide?

"There's probably not a one-size-fits-all answer," said Daniel McFarland, DO, a psycho-oncology fellow at Memorial Sloan Kettering Cancer Center in New York City. "There are good data, and there are good consensus arguments, and I think there's a lot of common sense that we could probably all agree on in terms of combating this problem."

The quote "physician heal thyself," is accurate when it comes to caring for physical health, because healthcare providers do a fairly good job of doing that. But not so for mental health, he said.

"We do an abysmal job at taking care of our mental health, and in a sense, we're almost a vulnerable population," he said. "I would make that argument, at least in terms of mental health."

Studies that have looked at ways to reduce burnout and depression — and hopefully prevent suicide — have looked at various interventions, from very simple to highly complex.

In one relatively simple intervention, for example, participants filled out a distress questionnaire (The General Health Questionnaire 12) and then received a letter in the mail explaining what the score meant and how they could help themselves. "And that actually had a beneficial effect," said McFarland.

Other studies have looked at interventions that were in-person and individual, interventions conducted online, and those conducted in a group setting, with varying methodology.

"Some of them involved what's called mindfulness — learning to do an attention and awareness intervention that can be taught and then experienced," said McFarland. "Some of them involve discussion and narrative for that expressive learning modality."

Overall, however, there are issues with these types of studies. They have variable outcomes, most are self-report, and few have hard endpoints, McFarland pointed out. "So in other words, what do you do to maintain someone so that they don't become burnt out? Or what do you do with a person who's actually burnt out?"

"I think in terms of getting to the heart of what is a good intervention for this, we need to look at the root causes," he added.

"A paper I read recently asked the question: Are we treating the symptoms and not the disease? And I think that's exactly the point. At the end of the day, this is essentially about a culture change," McFarland concluded.

American Society of Clinical Oncology (ASCO) 2019. Special session: "Elephant in the Room: Addressing Depression and Suicide Among Oncology Providers." Presented June 3, 2019.

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