Caring for oneself to care for others: physicians and their self-care

Predisposing factors

All physicians can be at risk for burnout as a result of both work and personal characteristics. Work factors include work overload (eg, large patient volumes, insufficient resources, or feeling poorly managed),⁶ lack of control over one's work environment, having the bulk of one's time at work spent on tasks inconsistent with one's career goals,⁶ and high levels of work-home interference.^6,7 Personal characteristics predisposing physicians to burnout include being female, working in a solo practice, being early in one's career,⁸ lacking a sense of personal control over events, and attributing success to chance instead of personal accomplishments.⁹ Being married and having children are protective against burnout, which may reflect the importance of nurturing personal relationships whatever their nature.¹⁰

Physicians caring for patients with terminal cancer are at particular risk for compromised well-being due to the nature and intensity of the clinical stresses they face. First, the growth in clinical workload outpaces the growth in capacity of the workforce. Between the aging population and advances in cancer treatment that help patients live longer, more patients are living with – and ultimately dying from – cancer and other serious illnesses.¹¹ Oncologists and palliative care physicians are also faced with increasing demand for end-of-life care as standard oncology practice shifts to include palliative care earlier in the treatment of metastatic disease.¹² Additionally, health care systems are under growing pressure to expand palliative care services.¹³ The National Priorities Partnership listed palliative and end-of-life care as one of six national health priorities with the potential to create lasting change. Good end-of-life care is increasingly seen as a measure of quality, as evidenced by the Joint Commission Advanced Certification in Palliative Care.¹⁴ In the face of this rapidly increasing clinical demand, however, both palliative care and oncology face a growing physician shortage.¹⁵ For example, Lupu and colleagues projected an acute shortage of between 6,000 and 18,000 palliative medicine physicians in the United States.¹⁶

Physicians caring for seriously ill cancer patients are also at risk for burnout because addressing end-of-life issues often requires facing resistance from patients and their families, colleagues, and institutional culture. Traditional medical culture views death as physician failure.¹⁷ Clinicians worry that talking about death implies “giving up” and will cause patients to be scared or lose hope. Creating relationships and maintaining rapport with patients and their families and with colleagues around the sensitive domains of prognosis and limitations to non-beneficial therapies can involve great intellectual and emotional investment. Clinicians caring for seriously ill patients in institutions where standards for end-of-life care are less developed can also find themselves alone in advocating for what they consider the best, most compassionate care. Some may experience moral distress when participating in care that feels like it increases suffering.¹¹

Another contributor to diminished personal well-being in physicians caring for terminally ill cancer patients is inadequate training in the management of pain and other symptoms and in communication skills.¹⁸ The idea that caring for complex patients with serious illness requires its own skill set is relatively new; palliative medicine was only recognized as a subspecialty by the American Board of Medical Specialties in 2006. A comprehensive review of the graduate medical education competencies for 29 medical specialties and 14 surgical specialties found a marked paucity of competencies in the area of symptom management and communication skills pertaining to end-of-life care. As a result, physicians can feel inadequately prepared to care for their patients facing terminal illness, be uncomfortable performing these skills, and experience dissatisfaction in providing less than optimal care.^11,19

Adequately trained physicians experience a high emotional toll when caring for patients facing serious illness. Doctors are repeatedly exposed to suffering in all its forms as patients face the incremental losses associated with progressive illness, including physical discomfort, decreased function, loss of professional identity, altered family role, and emotional and spiritual distress. Clinicians caring for terminally ill patients are often untrained in recognizing the personal emotional toll of caring for dying patients, and these emotions can go unexpressed and unrecognized.²⁰ Unexamined emotions, in turn, can lead to professional loneliness, loss of professional sense of meaning, loss of clarity about the goals of medicine, cynicism, hopelessness, helplessness, frustration, anger about the health care system, loss of sense of patients as human beings, increased risk of burnout, and depression.²⁰ Clinicians caring for terminally ill patients also must often face their own mortality and personal experiences with death and loss²¹ and confront grief and bereavement, which if unattended or avoided, may lead to further distress.²²

Impact of burnout, compassion fatigue and moral distress

The consequences of burnout, compassion fatigue, and moral distress are profound and range from personal crisis to suboptimal patient care practices.²³ Of the 3 conditions, the impact of burnout has been most closely studied. Burnout is most often measured through the Maslach Burnout Inventory,²⁴ but can be measured simply by using a single question such as “Do you feel burned out from your work?”²⁵ Burnout is a better predictor than depression of lower satisfaction with career choice and may be associated with both job turnover and poorer health.^26,27 It is also associated with important patient-related outcomes like medical errors by physicians, lower patient satisfaction, and longer post-discharge recovery by patients.²⁸ Furthermore, unprofessional conduct and less altruistic values are more common in physicians with burnout.²⁹

Less is known about the possible consequences of moral distress and compassion fatigue than burnout. Compassion fatigue may have signs and symptoms that mirror post-traumatic stress disorder, including hyper-arousal, avoidance, and re-experiencing events such as clinical encounters with suffering patients.^30,31 Moral distress results in serious adverse consequences including aggression, decreased job satisfaction, and professional exit.³² Not surprisingly, both moral distress and compassion fatigue can lead to burnout.

Self-care training and education for medical learners

Given the negative consequences of burnout, compassion fatigue, and moral distress, how well do we educate trainees to stay healthy and keep these dangers at bay? As a training domain, self-care is a spectrum of knowledge, skills, and attitudes including self-reflection and self-awareness, identification and prevention of burnout, appropriate professional boundaries, and grief and bereavement. Current evidence indicates that the medical student, resident, and fellow receive inadequate self-care training. In the accreditation standards for US and Canadian medical schools, the Liaison Committee on Medical Education, while highlighting the importance of student well-being, exposure to end-of-life care, and the provision of personal counseling as a resource, does not specifically identify self-care or other related areas.³³ Review of the literature reveals medical student curricula are focused on palliative and end-of-life care domains,^33–35 communication skills,³⁶ mindfulness,³⁷ and reflective writing and practice.³⁸ No published curriculum focused specifically on self-care or an integration of related areas was discovered. Similarly, the Accreditation Council for Graduate Medical Education (ACGME), which oversees the training of US residents and fellows, has not included self-care or specific related areas in its outline of competencies for trainees in all specialties, with the exception of education on sleep management.³⁹

Unlike specialty and other subspecialty areas, the subspecialty of hospice and palliative medicine (HPM) has recognized self-care as a critical aspect for satisfaction and longevity of its practitioners. Reflecting this, in 2007, HPM educational leaders recognized self-care as a specific competency area in creating national Core Competencies for HPM fellows in training, including detail on areas like self-reflection, self-awareness, bereavement rituals, recognition of burnout in self and others, and self-care planning.⁴⁰ These aspects were later incorporated into ACGME 2008 Program Standards for Hospice and Palliative Medicine fellowship training.⁴¹ In the subspecialty of hematology and medical oncology, the process and emphasis is different. Core competencies are generated more at the local fellowship program level instead of the national level, making content and trends harder to identify. However, the 2012 Program Standards for oncology fellowships mention the need for attention to professional boundaries and fellow coping skills but do not mention self-care or related realms.⁴² Please see Table 1 for a comparison of this content.

TABLE 1.

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Comparison of standards and competencies relevant to self-care areas for hematology and medical oncology versus hospice and palliative medicine fellow training

ACGME competency domain	ACGME hematology and medical oncology fellowship program requirements (2012)42	ACGME hospice and palliative medicine fellowship program requirements (2008)40	Hospice and palliative medicine core competencies (2007)41
Interpersonal and Communication Skills	Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.	Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.	The resident (fellow) should be able to demonstrate interpersonal and communication skills that result in effective relationship-building, information exchange, emotional support, shared decision-making and teaming with patients, their patients' families, and professional associates. 4.3. Demonstrates ability to recognize and respond to own emotions and those of others •Expresses awareness of own emotional state before, during, and after patient and family encounters •Reflects on own emotions after patient and family encounter or related event •Processes own emotions in a clinical setting in order to focus on the needs of the patient and family 4.6 Demonstrates the above skills in the following paradigmatic situations with patients or families and documents an informative, sensitive note in the medical record: •Saying good-bye to patients or families •Writing condolence notes and making bereavement calls
Professionalism	Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Fellows are expected to demonstrate: IV.A.5.e).(2) responsiveness to patient needs that supersedes self-interest; IV.A.5.e).(6) high standards of ethical behavior, including maintaining appropriate professional boundaries and relationships with other physicians and other health care team members, and avoiding conflicts of interest; IV.A.5.e).(8) personal development, attitudes, and coping skills of physicians who care for critically-ill patients.	Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. IV.A.2.e).(2) Fellows must demonstrate the capacity to reflect on personal attitudes, values, strengths, vulnerabilities, and personal experiences to optimize personal wellness and capacity to meet the needs of patients and families.	The resident should be able to demonstrate a commitment to carrying out professional responsibilities, awareness of their role in reducing suffering and enhancing quality of life, adherence to ethical principles, sensitivity to a diverse patient population, and appropriate self-reflection. 5.1. Achieves balance between needs of patients/family/team, while balancing one's own need for self-care  5.1.1. Recognizes the signs of fatigue, burnout, and personal distress, and makes adjustments to deal with it  5.1.2. Describes effective strategies for self-care, including balance, emotional support, and dealing with burn-out and personal loss  5.1.3. Contributes to team wellness  5.1.4. Explains how to set appropriate boundaries with colleagues and with patients and families 5.5. Fulfills professional commitments  5.5.5. Addresses concerns about quality of care and impaired performance among colleagues 5.7. Demonstrates respect and compassion towards all patients and their families, as well as towards other clinicians  5.7.1. Demonstrates willingness and ability to identify own assumptions; individual and cultural values; hopes and fears related to life-limiting illness and injury, disability, dying, death and grief 5.8. Demonstrates the capacity to reflect on personal attitudes, values, strengths, vulnerabilities, and experiences to optimize personal wellness and capacity to meet the needs of patients and families

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Self-care tools and strategies

Given the inadequacy of self-care education for physicians caring for terminally ill cancer patients, we must ask how these physicians can be better equipped to face the stresses inherent in the work. Improving physicians' wellness and implementing self-care strategies is a multifactorial process⁴³ and includes attention to both personal and professional self-care. Personal self-care refers to strategies for individual physicians to take better care of themselves. It starts with the recognition that people have multiple personal dimensions to attend to in order to live a “good” life⁴⁴ including inner lives, families, work, community, and spirituality. Strategies for personal self-care include prioritizing close relationships such as those with family;⁴⁵ maintaining a healthy lifestyle by ensuring adequate sleep, regular exercise, and time for vacations;⁴⁶ fostering recreational activities and hobbies;⁴⁷ practicing mindfulness and meditation;⁴⁸ and pursuing spiritual development.⁴⁹ A widely available instrument called the Wellness Wheel refers to 6 types of wellness – physical, intellectual, emotional, spiritual, social and occupational – and allows individuals to reflect on current life balance and self-care.⁵⁰ Individuals using such a tool can improve job satisfaction and overall well-being, reducing the likelihood of stress and burnout.

The importance of developing self-awareness deserves particular attention as a realm of self-care. Self-awareness, defined as a clinician's ability to combine self-knowledge and a dual-awareness of both his or her own subjective experience and the needs of the patient, has been identified in the field of psychology as the most important factor in the psychologists' ability to function well in the face of personal and professional stressors.⁵¹ Greater self-awareness among clinicians may lead to greater job engagement and compassion satisfaction, enhanced self-care,⁵² and improved patient care and satisfaction.^20,53 Conversely, clinicians who possess lower levels of self-awareness have a greater likelihood of compassion fatigue and burnout. Data support mindfulness meditation and reflective writing as 2 methods of enhancing self-awareness. Mindfulness meditation involves developing purposeful attention, in the present moment, and cultivating a kind, nonjudgmental attitude towards self and others.⁵⁴ Several randomized trials have studied the effects of mindfulness-based interventions for health care professionals,⁵⁵ nursing students,⁵⁶ and medical and premedical students.³⁷ The benefits of these interventions included enhanced sense of well-being, increased empathy, and decreased anxiety. Reflective writing, another tool to enhance self-awareness, has been shown to promote reflection and empathic engagement in physicians.^57,58

Along with personal self-care, professional self-care strategies are helpful in decreasing burnout, compassion fatigue, and moral distress. Since seriously ill oncology patients require a team of inter-professional experts to deliver comprehensive care, professional well-being must include both individual and team-based self-care. Examples of individual professional self-care include regular appraisal of all aspects of work life⁵⁹; developing a network of peers and mentors⁶⁰; seeking organizational engagement opportunities⁶¹; improving communication and management skills⁶²; increasing self-awareness in setting limits⁶³; and pursuing reflective writing.⁶⁴ Team self-care relies on team structure and team processes as important contributing factors to a team's well-being.⁶⁵ Strategies include improving team members' skills to empathize with others⁶⁶; formalized structures, policies, and procedures to guide team meetings; and sharing personal and professional sources of meaning.⁶⁷ Several studies have recognized the benefits of coordinated inter-professional team care and subsequently, inter-professional education.⁶⁸

Conclusion

Clinicians who care for seriously ill cancer patients are at high risk of developing burnout, compassion fatigue, and moral distress by virtue of the challenges presented in the daily care of these patients and their families. The impact of these syndromes can be severe and far-reaching. Given the lack of adequate focus on the importance of caring for one's self in the training of future oncologists and palliative medicine physicians, those practicing in these fields should develop a self-care plan. Fortunately, as described above, self-care strategies exist in both the personal and professional realms with proven benefits in mitigating the effects of burnout, compassion fatigue, and moral distress. This paper discusses potential threats to self-care and summarizes multiple strategies to promote well-being for physicians caring for patients with advanced cancer (Table 2).

Importantly, self-care has the potential not only to minimize the harm from burnout, compassion fatigue, and moral distress but to promote personal and professional well-being. Job engagement (marked by efficacy, energy, and involvement in work),¹ compassion satisfaction (the pleasure derived from being able to do one's work well when helping others,⁶⁹ and resilience (the ability to respond positively to challenging experiences) are all possible outcomes when a physician's personal well-being is carefully tended. If these qualities are supported and strengthened, the very characteristics of the work of caring for patients with advanced cancer that convey such risk for harm to physicians can instead bring great gratification and a sense of professional and personal purpose. Providing care for patients at a most vulnerable time in their lives and helping ease their suffering can give physicians a sense of self-efficacy, strengthen their sense of connectedness and idealism, and remind them of the preciousness and fragility of life. These experiences, if recognized and fostered, can in turn underscore the importance of self-care, including living in the present, cultivating meaningful personal and professional relationships, attending to a spiritual life if significant to each individual, and developing self-awareness. Lastly, if truly embraced, the precepts and benefits of good self-care can be conveyed to the next generation of physicians, both formally as such principles are integrated into training, and informally as preceptors and mentors model these attitudes and skills for their trainees. Only with such efforts can the increasingly challenging work of caring for these complex cancer patients become sustainable for the physicians who choose to do it.

So, what is your self-care plan?