I have heard many descriptors for the field of oncology over the years, but I must admit that when my resiliency coach referred to it as “relationship-intensive,” it was the first time I had heard such a description. Asked to elaborate, he explained that when patients are confronted with a diagnosis of cancer, the other problems, issues, and stressors of life seem to drop down on the priority scale while the cancer takes over. As part of the new focus, the relationship between patient and oncologist often takes on an intensive, even personal, dimension that eventually can become burdensome. I have experienced an intensifying relationship with patients and their families countless times, but what the coach said next was what really surprised me—that the variable in this equation that has changed the most over the last decade is time.
Through clinical research, we have made substantial progress in extending the survival of patients with advanced-stage cancers, such that the majority of patients who have metastatic disease now live for 5 to 10 years or longer. Some 10 years ago, we might have had two or three lines of therapy we could try to achieve a partial response or stable disease in patients with solid tumors or hematologic malignancies. Now, we usually have 5 to 10 potential lines of treatment available. Of course, some patients’ cancers still progress rapidly, and they never make it to second- or even first-line therapy. The majority of the patients we see, however, are long-term responders who return to our clinic periodically for years, thanks to targeted therapies based on genetically enriched tumor profiles, along with the use of immunotherapy combinations. These patients are grateful for their good fortune. At the same time, they remain anxious about what lies ahead.
When I first went into oncology more than 20 years ago, I had the occasional patient who would experience an exceptional response to treatment and live way beyond the median life expectancy. I do not think of myself as playing favorites, but these rare cases were always memorable. I got to know these patients on a more personal level, and consequently, I also opened up to them. When they eventually progressed through multiple lines of therapy and died, it was as if I had lost a close friend or family member. Now that those formerly rare circumstances are becoming routine, I still find myself regularly drawn into patients’ lives and sharing more of my own life with them in turn. In short, the relationship side of oncology is taking up more and more of our emotional reserves.
Please do not misunderstand me. I think that anyone drawn to medicine has some expectation of, even an affinity for, developing good communication skills. Oncology, in particular, has evolved into a relationship-intensive field. These relationships with patients, however, can cloud our judgment regarding appropriate end-of-life decisions, in turn driving up patients’ stress, anxiety, cost, and suffering in their last year of life. So, what can we do about this?
I believe the first step in dealing with the increased emotional burden of care is to talk and share experiences with colleagues. At Duke, we have a weekly meeting of the health care providers in our genitourinary oncology group, and we have begun reviewing cases that are causing us to feel conflicted or where we struggle with end-of-life decisions. Supporting one another in this group with objective advice and feedback has helped relieve some of the pressure of being both a managing physician and a friend to our patients. In addition, we have contracted with a resiliency consultant to work with us both individually and as a group to help us appreciate the burden of our profession and support one another through times of stress throughout the workday. I can say that for me, at least, the input of the resiliency consultant has helped, especially during this year of social isolation. Most of my interactions with colleagues are through Zoom meetings rather than in person. Clinic remains the one place where these relationships and associated concerns are still face-to-face and interpersonal. With no professional travel and limited face-to-face interactions with colleagues outside clinic, the additional support efforts have been a lifeline as we get through some difficult cases. Although efforts like these are a small counterbalance to the growing demands on our time and emotional energy, it is vital that we recognize the drain we may be feeling and intervene. Oncology has one of the highest rates of burnout, with a recent ASCO poll showing that 45% of medical oncologists have reported emotional exhaustion. Counterbalances to such exhaustion are critical for all; we need to remain emotionally healthy in order to take the best care of our patients.
Daniel J. George, MD