I was called to the hospital to see a 26-year-old patient with multiple liver lesions. He had felt well until a few days before his hospitalization, when he presented with abdominal pain. A few days later he was diagnosed with multifocal hepatocellular carcinoma and Child’s class C cirrhosis. I discussed the grim prognosis with the patient, his wife, and 20 of his family members and explained that there were no treatment options available besides supportive care. Shortly after this conversation he was discharged from the hospital and then received support from home hospice services.
My immediate response to this scenario was not too notable, as this was the end of my first year of oncology fellowship and I had encountered similar situations throughout the year. However, I later noticed my response to this and cumulative other events when my 3 year-old daughter lost her balloon out the car window a few weeks later. My response to her tears was simply, “Well, that just happens.” This reaction, with its abundant lack of empathy for what was a significant loss for her, reinforced to me that my clinical exposure to patients can impact my emotional responses to my family and others in my life.
I have attended a number of lectures during training that have discussed the topic of burnout. These thoughtful talks included a list of symptoms, most of which I could recognize in some form or another in myself, and provided suggestions on how to deal with them. I usually left such lectures without any change in behavior on my part, rationalizing, “I will just tough it out.” Often, the major cause of burnout is attributed to the amount of time that we as physicians spend working. After one of these talks, I wondered why the medical field is particularly vulnerable to burnout when so many other careers are prone to long hours as well.
I found a description that partially explains this vulnerability to burnout in Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others. The book, written by Laura van Dernoot Lipsky and Connie Burk, has improved my understanding of a process the authors call trauma exposure.1 They define trauma exposure simply as “the fact that we are affected by the suffering of others.” This response to suffering is something I had noticed already, but I ignored its significance until I read their description. As I’ve investigated this further during my clinical rotations, I believe an understanding and dedicated response to trauma exposure is essential to enabling a career of consistent, quality patient care.
Given the abundance of new and difficult situations that oncology fellows face during training, the likelihood of developing symptoms from trauma exposure is high, though it is clearly not unique to the training portion of our careers. While we commit to doing our utmost to relieve the suffering of our patients whenever possible, each emotional episode and undesired outcome that we witness has the potential to cause us to feel that we are primarily responsible for the outcome. During fellowship training, when our knowledge gap is larger and the fear of missing something is greater, this tendency to feel inappropriate responsibility increases proportionally. I believe that an inappropriately high assumption of responsibility for patient suffering contributes to burnout while an inappropriately low level of responsibility is symptomatic of burnout. Our goal must be to remain between these 2 extremes.
Part of the tendency to accept an inappropriate amount of responsibility for patient outcomes is rooted in a belief that suffering occurs for a reason. We may not believe this strongly enough to vocalize it, but I think many physicians utilize this belief for the protection it provides. If we acknowledge that we witness undeserved suffering we must also acknowledge that similar suffering could interrupt our own lives. This realization is difficult, and avoiding it in the short term can be easier than confronting our own vulnerability. A problem that arises with avoidance of this realization is that the emotional distance necessary for this defense weakens our empathy for the patient in front of us; this in turn contributes to decreased job satisfaction and burnout. Therefore, we must develop the skill of acknowledging suffering, recognize our appropriate role within it, and continually care for ourselves in order to sustain our careers in oncology.
When we appropriately handle our response to trauma exposure, our patients benefit and our ability to develop our careers during fellowship is positively impacted. Symptoms of trauma exposure include decreased creativity and motivation, fatigue, and physical ailments, which can delay or limit career choices due to a perceived or actual lack of productivity. Other symptoms of trauma exposure and burnout include a decreased tolerance of ambiguity, a potentially dangerous symptom when premature diagnoses can lead to adverse patient outcomes. Because of its significant impact on clinical, professional, and educational growth, I believe improving our response to witnessed trauma should be a measured goal of fellowship training, prioritized alongside clinical training by fellows and program leadership alike.