Apr 9, 2020
Dr. Pennell talks with Dr. Daniel Richardson discuss physician burnout and the author’s curriculum designed to mitigate burnout and foster solidarity among fellows.
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Hello, and welcome to the latest JCO Oncology Practice podcast,
brought to you by the ASCO Podcast Network, a collection of nine
programs covering a range of educational and scientific content and
offering enriching insight into the world of cancer care. You can
find all recordings, including this one, at podcast.asco.org. My
name is Dr. Nate Pennell, medical oncologist at the Cleveland
Clinic and consultant editor for the JCO OP.
Today, I'd like to talk about a topic that's at the front of many
people's minds, burnout. With what seems like constant stress and
increasing demands on our time, many clinicians are feeling
increasingly exhausted, cynical, and like their work lacks meaning.
These elements are part of a condition known as burnout. And it
feels like everyone's feeling it to a greater or lesser extent
these days. While employers and training programs are increasingly
aware of the issue of burnout, what are they doing to reduce it or
to prevent it from happening in the first place?
With me today to discuss this topic is Dr. Daniel Richardson,
hematology/oncology fellow and AHRQ postdoctoral research fellow at
the UNC Chapel Hill Lineberger Comprehensive Cancer Center. We'll
be discussing his and his colleagues' paper, "Development of an Art
of Oncology Curriculum to Mitigate Burnout and Foster Solidarity
among Hematology/Oncology Fellows," which is part of a special
series at the JCO OP on physician wellness burnout and moral
distress. Welcome, Daniel, and thank you for joining me on the
podcast.
Thanks for having me. It's really a privilege to speak with you
today. I'll start off just by noting my conflicts. I have no
financial conflicts of interest to disclose. However, my
institution was involved in the study that we'll be talking
about.
All right, thanks for that. So burnout is something I think most
physicians and other clinicians can relate to. But would you mind
just kind of giving our listeners a little brief overview of what
exactly is burnout in physicians and how big of a problem is this
right now?
Sure. So burnout was first described really as a metaphor to talk
about an extinguishing of a fire or smothering out of a fire. And
it related to this loss of capacity that many feel to make a
meaningful and lasting impact with one's life or career.
More recently, it's been further clarified to cover several domains
of this initial concept, including emotional exhaustion,
depersonalization, and loss of meaning or purpose at work. And
burnout really has been shown to lead to profound of personal and
professional consequences-- anxiety, depression, and in the
professional realm, attrition among physicians and oncologists and
decreased quality of care. And the problem is pretty pervasive, as
most of us are aware. Our most recent studies show that nearly half
of practicing oncologists are experiencing burnout and about a
third of residents, fellows, and medical students even are
experiencing burnout.
Yeah, this is what, I think, a lot of our listeners might be
interested to hear about. There may be a conception out there that
burnout is a function of time-- you know, being exposed to
something over a long time maybe later in your career. But what
you're saying is that this is something that people can start to
experience almost immediately, even in medical school and during
residency. And I find that really interesting, although potentially
disturbing as well.
Yeah, I agree. And I think what we're seeing is probably the
results of a larger change in our culture. We're seeing kind of a
loss of sense of meaning and purpose and connectedness to the
community in the larger culture. Increasingly, we're seeing that
medical students, residents, and fellows are lacking a deeper sense
of meaning and purpose in the broader community. And that's really
playing out in their role as an oncologist as well.
So I'm curious what led you and your fellowship program to
developing this kind of a curriculum to try to combat burnout.
Sure. Prior to medical school, I completed a master's degree in
philosophy of religion and ethics. And it allowed me the
opportunity to think a lot about virtue ethics and also the moral
foundation of medicine. And virtue ethics is really focused on
human flourishing and really claims that the path to human
flourishing is developing character and virtues that can lead to
that.
And so I thought a lot about who I was becoming as a medical
student, who I was becoming as a physician in medical school and
then into residency. During my first year of fellowship, I was
thinking a lot about the culture of medicine and how I was
developing in the midst of that. And I really became aware that
there was a clear lack of direction on how to help fellows develop
into oncologists that would be able to thrive in their careers.
We didn't really talk about calling. We didn't talk about purpose.
We didn't talk about who we were becoming. We were being trained as
oncologists with the right answers about treatment. But as one of
my favorite authors, C.S. Lewis, puts it, we were at risk of
developing into oncologists without chests-- that is, without a
deeper understanding of the meaning and purpose of what we did each
day. It really kind of started with this bigger understanding that
we were going through this big process, and we were becoming
oncologists without really thinking about what that process was
looking like and how that was happening.
Wow, I think that is-- that's fascinating. Well, in any case, since
this led you to design the program, can you take me through the
design of the Art of Oncology program that you designed? And what
are you hoping to show as a result?
Sure so as I had mentioned, I was really thinking a lot about who
we were becoming as oncologists. And so one of the first things
that I thought about is, how can we foster a sense of meaning and
purpose in our fellows. I thought that this was really a place
where we are seeing a lot of burnout is that there is this lack of
meaning and purpose among fellows and oncologists in general. And
so we wanted to target that. So we landed on a curricular
intervention that used narratives, really to promote a shared
mental model of meaning and work, which all that really means is
helping all of us have a discussion to understand where we are
coming from, our experiences, and how we are being shaped in the
midst of kind of caring for patients. And our hope in kind of
starting from that point and developing a narrative model was
really that we could help fellows understand where they sat in
caring for patients, their calling in doing that, and then also
their position as a part of a broader community that had a bigger
vision for caring for patients as well.
So we decided that we would use personal and published stories,
mostly about caring for cancer patients, to spark discussion,
reflection, and then really a deeper understanding among fellows of
this shared calling. And we had faculty or, often, patients come
and share their story or one of the narratives in those sessions.
We planned eight sessions throughout the year, which took place
during the traditional didactic lecture times. And the narrative
took place over the first 15 minutes or so. And then the point was
really to foster this deeper discussion and reflection on meaning,
identity formation, and moral development in medicine.
So a lot of this really was based, then, upon selecting the
different essays and other pieces of literature that you were
discussing. So how did you end up picking those?
That's a great question. And I think we wrestled with it a lot. I
think initially, we, as a group, found those essays that were most
meaningful to us. And we felt like they would really speak to the
fellows. But as we thought about it more, we really wanted to
collect them around a few themes. And as I've been talking about, I
fundamentally believe that finding meaning in caring for suffering
patients is essential to mitigating burnout. So this was kind of
the primary theme that I focused on.
But we also, in the midst of the program, wanted to equip fellows
with skills to foster their sense of purpose in medicine. So we had
a session focused on cultivating virtues of resilience and
self-care, as well as sessions on caring for dying patients. And we
really understood that the experiences of most fellows were very
hard, given the immense amount of suffering that they
experience.
So our initial hope would be that really, this session and this
program would be an avenue to redeem some of the suffering that the
fellows were experiencing through their patients. We hoped that it
would lead to a deepened sense of community or solidarity is the
word I use in the paper, among our fellows, and that this sense of
belonging in one's profession really becomes vital for the
sustained success. And I was really hoping that this would be
fostered in the program as well.
You had mentioned earlier about what you were hoping for. Although
we knew that we wanted to target a reduction in burnout among
fellows, we recognized that burnout is really a multifaceted
concept. So we knew that a small pilot program would be unlikely to
see a substantial improvement in burnout. But we wanted to really
shoot our or our aim our intervention really at the roots of
developing burnout over a career.
So how did you try to measure that? So I mean, first of all, I've
got to say, this sounds amazing. And I could say it may have value
just in and of itself, because it's such an interesting and cool
concept. But as scientists and trying to study things, how would
you measure this kind of improvement?
Yeah, so that is probably the fundamental challenge, to be honest.
And I, first off, want to say, I 100% agree with you. I think it's
a first principle of medicine that we need to, as a community,
think deeply about how to care for patients well. And we need to
help each other to thrive in medicine. So I don't know how you'd
necessarily capture that on a scale.
There are well-developed burnout scales, the NBI being the most
prominent. We worry a little bit about having our fellows go
through extensive surveys in the curriculum. So we used a couple
surrogates. So there are three one-item measures that we used at
the beginning and then the end of the curriculum.
And then we really wanted to capture the experience of the program
as well. So we had fellows fill out basically subjective surveys
about their experience with the program. And then also, we captured
their attendance in the program. Our aim was really to establish,
first off, is this something that is possible to do, good
fellowship programs do this. And then really, did fellows enjoy and
participate in the program as well.
You mentioned about not wanting to put a bunch of surveys on top of
people. And so one of the first things that occurred to me when I
was reading this paper is, were you concerned when discussing
adding this that fellowship curriculums are already quite busy and
filled with lots of sessions and other duties and whether this
might actually make their burdens worse by adding extra sessions
and requirements?
Yeah, for sure. We didn't really know what to expect. And we didn't
even know if the Fellows would show up and participate. There is
fear within our culture of being vulnerable, of owning that the
suffering of our patients is getting to us and that we need some
help. And I was really afraid that fellows would feel like the
sessions were cheesy or forced and that the fellows would be
uncomfortable being honest in the sessions.
There is a perpetual concern about adding more into the lives of
fellows that will lead to greater burnout. You know, it's the
running joke about filling out a weekly 25-question burnout survey
among our fellows. So we really wanted to design a program to limit
the requirements. Fellows really just had to show up and
participate. There is no required readings or homework.
And we limited a few didactic sessions that used to be in the place
where the Heart of Oncology sessions were in order to make room in
the schedule. And we tried hard to make the sessions adaptable to
any environment so that it was really just having a narrative
prompt, getting people who care for cancer patients together, and
thinking deeply about some of these issues that was really at the
heart of the program. So we tried to limit a lot of those extra
requirements for the program.
Well, it sounds like you definitely thought about that and tried to
make it as least burdensome as possible. And it sounds like you
were able to do that. So tell me, what did you learn from this
first year of the program?
Well, it was really fun at first. And so as a fellow myself, I was
able to participate with the other fellows. And that was really
wonderful. I had a great time with them and learned a lot about
them and felt like it was really enriching for me.
We saw, really, that the fellows really enjoyed the curriculum as
well. They really loved the opportunity to think more deeply about
these issues and also to hear how their colleagues were wrestling
with them and to dialogue about some of the issues that we often
don't talk about. They felt it improved the sense of community
among the fellows and helped with some of the daily challenges of
dealing with the suffering of their patients.
They pointed to some practical skills that they took away from the
sessions, including managing work-life balance, communicating bad
news, and having a better understanding of the challenges faced by
patients. Surprisingly, many of the sessions were really emotional
for the fellows, where they were able to share their stories about
losing patients or family members to cancer.
We didn't see a statistically significant improvement in burnout.
And as I mentioned previously, this is a pilot intervention. So
this is not wholly unexpected. As you mentioned prior as well, that
with such positive comments from the fellows that the sessions were
beneficial in and of themselves, and really that we would hope that
there would be long-term benefit as well. I don't know if such
programs to foster moral development would actually be expected to
result in immediate improvements in burnout. So the goal was really
to begin to cultivate the virtues that will have lasting impact
over a career in medicine and not necessarily to impact the burnout
that follows were experiencing in that moment.
So you are describing the first year in your paper here. So what
are the next steps? And based on what you've learned, are you
planning any changes?
Yeah, so Dr. Collichio and I sit on the ASH ASCO Milestones
committee, which are working to develop some metrics to capture
fellow well-being at each fellowship program. And so we are hopeful
that these metrics begin to lay a foundation to expand the art of
oncology programs and other fellowship programs. We've been in
contact with other programs that are eager for such an intervention
and to get it rolling. And so I welcome other fellowship programs
to join in as well.
The ideal study design to test this intervention is a
multi-institutional cluster randomized trial. But really, I think
we're still at the nascent stages of the development of such
interventions. So this will likely be something that will happen
years from now. And again, I think we realize that while we want
this intervention to really impact on burnout, we want the
intervention to have something deeper in terms of developing the
character of our fellows. And so rolling it out among fellowship
programs is going to have benefit across the board.
So what changes are we making to the program? We're in the second
year of the pilot. And we haven't had too many changes, apart from,
again, limiting the amount of requirements that we have for the
fellows. Last year, the fellows really loved having patients come
and speak and share their stories and how they interacted with the
health care community. So we increased the number of times that
patients would be coming. And we started to have more of our senior
oncologists come and share their journey in medicine, kind of a
career perspective to the fellows, and allow them to really begin
to build some mentoring relationships.
Well, Daniel, I think this sounds absolutely fantastic. I wish we
had something like this when I was going through fellowship
training. So Daniel, any closing thoughts before we wrap up?
I'd like to comment that programs like these are simply part of a
larger whole. Much of the increase in burnout we are seeing in
medicine, as I mentioned, is part of larger societal epidemic of
the loss of meaning and purpose for individuals. I believe that the
epidemic of burnout in medicine is not going to simply be reversed
by programs, but rather by a deeper change in the culture.
As an oncology community, we need to recapture our calling of
service to suffering patients. We need champions who can lead the
way in this and serve as mentors for fellows on how to care for
patients well and to model how to find joy in their careers despite
the suffering and losses they experience. It is only by recapturing
this deeper calling that we can inspire and train fellows to do the
same. And I'm hopeful that programs like this one and other similar
programs across the country to bring fellows together to think
deeply about their calling, their personal calling, and then also
their calling in the midst of the oncology community, will serve to
do this as well.
So Daniel, thanks so much for joining me on the podcast today.
Once again, this is such a privilege. Thanks so much for having
me.
And until next time, thank you for listening to this JCO Oncology
Practice podcast. If you enjoyed what you heard today, don't forget
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JCO Oncology Practice podcasts are just one of ASCO's many podcast
programs. You can find all recordings at podcast.asco.org. The full
text of the paper is available online at ascopubs.org backslash
journal backslash JCO OP, posted in February 2020. This is Dr. Nate
Pennell for the JCO Oncology Practice signing off.