Delivering a diagnosis that no one wants to hear. Getting a positive response to a new therapy. Telling a patient her cancer has progressed—or that she is finally cancer-free. Perhaps no medical specialty encompasses as many dramatic highs and lows, sometimes in the course of a single day, as oncology.
By Barbra Williams Cosentino Photos by Tommy Leonardi
While acknowledging that their jobs can be stressful and difficult, clinicians who treat cancer patients say their work also yields deep satisfaction. As longtime medical oncologist Mary B. Daly puts it, “I always feel both drained and enriched after a day in the clinic.” The challenge, experts say, is to find a balance between engaging emotionally with patients and maintaining the boundaries that help them practice effectively in the long term.
When people ask medical oncologist Crystal S. Denlinger about her occupation, she says, “they are always surprised to learn how much I love my job.”
Denlinger, who chose her career as a teen while her father was being treated for kidney cancer, says she considers it “a privilege” to care for oncology patients. “The relationships between physician and patient that develop during treatment are very special,” she explains. “I am intimately involved in my patients’ lives.” While she finds it “extremely satisfying” to cure many of her patients, she notes that she can still have a positive impact on those she cannot cure, “whether by improving their quality of life or extending their years on this Earth.”
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It is perhaps no surprise that caring for cancer patients comes with certain challenges. A 2006 article in Palliative and Supportive Care that reviews research on the topic notes, “Cancer is a psychologically and physically threatening disease. Health care providers empathize with their patients’ losses and . . . may feel a personal sense of failure or futility.” The authors add that “working ‘on the edge’ between life and death poses daily psychosocial challenges and forces one to become acutely aware of the fragility of life.”
Margaret von Mehren, a medical oncologist who heads Fox Chase’s sarcoma program, says her work has given her a new perspective. “When I work with patients, it gives me insight into what’s really important,” she says. “As I watch them struggle to reorient their whole way of living to deal with their disease, it reminds me that there’s more to life than having your next success.”
THE COST OF CARING
The very aspects of clinicians’ work that can be most rewarding—such as relationships with patients and their loved ones—can also present the most challenges.
Von Mehren sees some patients over the course of many years. In some cases, their sarcomas are not curable. “There are always feelings of loss when someone you’ve been treating for years dies,” she says. “You’ve watched their children grow up and shared life experiences with them, and the ending feels profoundly sad.”
Medical oncologists aren’t the only ones to face such losses. Head and neck surgeon John A. “Drew” Ridge takes issue with the conventional wisdom that surgeons, who typically spend less time with patients than do their medical peers, are less emotionally engaged. “Surgeons are oncologists,” he says. “When we work with patients who have cancer, the stakes are high. Even when the prognosis is very good, to a patient a diagnosis of cancer is life-changing. Every interaction is potentially difficult for both patient and doctor.”
Research indicates that the emotional toll of clinical oncology can include feelings of powerlessness, failure, and guilt. Von Mehren is keenly disappointed when treatments don’t work as well as she had hoped. “When I know that, theoretically, particular patients should do well but don’t, I am frustrated by my inability to turn things around,” she says.
Self-doubt can compound such feelings. “Sometimes it’s difficult not to beat yourself up or second-guess yourself,” says medical oncologist Elizabeth R. Plimack, who treats patients with kidney, bladder, prostate, and testicular cancer. “You can’t be a good physician without revisiting the decisions you’ve made, but a negative outcome should not be viewed as a personal failure.”
Clinicians are sometimes particularly affected by certain patients. They might identify with a patient who is of similar age, for example, or a patient might trigger memories of a lost loved one. Von Mehren, whose mother died at 61 of lung cancer, says she feels a particular pang when treating a middle-aged woman with the disease.
But research has found that embracing the emotional components of caring for cancer patients yields benefits for both patient and practitioner—including improved care and recovery, reduced anxiety for clinicians and patients, and lower rates of malpractice. A study published in Psycho-Oncology in 2005 found a “human connection” between physician and patient to be a “universal ingredient of effective cancer care communication.”
“You cannot separate yourself from the emotional aspects of taking care of someone,” says pain and palliative care physician Marcin Chwistek. “Emotions are what connects us to patients; clinicians just need to learn to recognize and manage them. As a clinician, understanding your emotions helps you take better care of the patient, but it also helps you take better care of yourself.”
Caring for oneself emotionally can help clinicians avoid the syndrome known as “burnout.” Psychologist and burnout expert Christine Maslach defined the condition as a feeling of emotional exhaustion; depersonalization, or detachment from one’s work; and a reduced sense of personal effectiveness. Burnout has been linked to increased rates of medical errors and decreased patient satisfaction.
A survey published in Journal of Oncology Practice in 2005 found that more than 60 percent of American oncologists reported feelings of burnout, with the top three signs being frustration, emotional exhaustion, and lack of satisfaction with work. Other studies have identified burnout rates ranging from 30 to 50 percent among oncology clinicians.
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A LARGER ROLE
Focusing on the many ways they serve patients beyond treating their disease—from educating to providing comfort and understanding—helps clinicians stay in touch with the contributions they make.
“After their diagnosis, some patients do online research and find articles that impart information in the most negative light, which can lead to a ‘doom and gloom’ attitude,” von Mehren says. “I find it emotionally and intellectually satisfying to help patients understand more about their disease, clear up misconceptions, and give them an honest picture of what will happen next.” Like many of her colleagues, she also takes satisfaction in knowing that her participation in research and clinical trials could help to develop more effective treatments in the future.
Communicating honestly with patients about their medical situations and treatment options can be important for both physician and patient, Chwistek says: “Discussions around healthcare decisions can be draining, but there is a real sense of being helpful when the conversations help patients to make decisions that are congruent with who they are.”
Veteran nurse Celeste Schiller, who has cared for hospitalized cancer patients for more than 20 years, says she focuses on her ability to make a difference however she can: “It is very gratifying when I can help my patients maintain hope that they can meet some of their goals, such as going home, in spite of their illness.”
Assisting patients in coming to terms with their situations can be deeply fulfilling, says surgeon Ridge. “One of my major rewards is helping people to find satisfying ways of living despite having had cancer,” he says, “and without being crushed by fear.”
HELPING THE HEALERS
Remaining alert to circumstances that might activate emotional reactions—such as encountering patients who bring up painful memories—can be the first step toward managing those reactions, says Luanne Chynoweth, director of social work services.
“Social workers receive lots of training around self-awareness. We’re always looking at what can get triggered for us personally,” she says. “Having that awareness allows you to share and connect while also maintaining effective professional boundaries.”
In a March/April 2007 Oncology Issues article, Chynoweth and former colleague Joan Hermann describe a mindset of “detached engagement”: “A patient touches our heart and we respond with genuine feeling and concern. … We remain emotionally engaged but able to guide the patient through the minefield of feelings and experiences that characterize a life-altering disease.”
Social workers strive to avoid conveying any personal pain they feel through such engagement, Chynoweth explains: “We do not want to telegraph emotional distress to our cancer patients, who then feel a need to ‘care for’ their professional caregiver.”
Striking a balance between emotional engagement and professional distance is no small task, however. “It is always challenging to set internal boundaries so that my patient’s emotional pain does not become my own,” Schiller says. “At a certain point, perhaps five or six years into practice, oncology nurses either grow in their ability to be deeply engaged with their patients without getting consumed by feelings of sadness or loss, or they leave the bedside.
“I encourage younger nurses to focus on their ability to make a difference in the lives of patients,” she adds, “but to also develop the ability to leave work at work.”
Opening up to colleagues about emotionally difficult situations can bring relief. “Talking through a difficult situation can enable physicians to confront their own emotions … reduce isolation and help build the network of support that is necessary for complex and demanding clinical work,” notes a 2001 article in Journal of the American Medical Association. But physicians may resist discussing the personal challenges they encounter.
Chwistek points out that traditional medical teaching held that emotions interfered with physicians’ work; doctors were taught to be objective and not let their feelings get in the way. “It has been deeply encoded in our brains to deal strictly with medical facts rather than to share the emotional challenges of our work with colleagues,” he explains.
To give physicians a forum in which to safely process their experiences, Fox Chase hosts the Schwartz Rounds, a bimonthly meeting designed for clinical staff to discuss challenging cases. Part of a national program based at Massachusetts General Hospital, the sessions aim to provide support to caregivers and improve their communication with each other and with patients.
“Being able to say what you’re thinking is therapeutic,” says Hossein Borghaei, chief of thoracic medical oncology, who shared a case at Schwartz Rounds involving a patient in her 30s who died of lung cancer, despite his efforts. “It’s good to get it off your chest.”
A PROFESSION AND A VOCATION
How oncology clinicians manage the psychological and emotional challenges inherent in their work may depend on the individual.
“Not everyone is cut out to do this work,” says Ridge. The bluntness of his words matches his affect; Ridge acknowledges a bedside manner more reserved than cuddly. But the gruffness belies an unyielding dedication to his patients—a commitment that extends far beyond the operating room. “If I cure them, I follow them for 10 years,” he explains. “If I don’t, I follow them until their treatments end—sometimes until they die.”
Ridge says he became an oncologist in part to “assume some of the weight” of cancer patients’ emotional and psychological burdens. After two decades, that interpersonal connection helps to keep him motivated. “You never hate cancer any less,” he reflects. “You never get tired of the struggle. … But conquering the cancer is insufficient; you have to care about the patients.”
Ridge views his occupation as more than a job. “Being a cancer specialist is a chosen profession and a vocation,” he says. “Many are drawn by the satisfaction of helping people in their time of greatest need.”
But make no mistake, he adds: “The job is hard. You don’t stay at it long if you don’t find a way to deal with it.”
Barbra Williams Cosentino is a registered nurse, clinical social worker, psychotherapist, and freelance medical writer based in New York.