Cancer and Palliative Care Anthony Back MD Seattle Cancer Care Alliance University of Washington Fred Hutchinson Cancer Research Center

Hospice Curative / remissive therapy Presentation Death The old way of thinking

Hospice Palliative care Curative / remissive therapy Presentation Death A new way of thinking

Communication is like sex You are supposed to know how to do it already 5% of oncologists have had formal communication training In another ASCO survey, oncologists cited “traumatic experiences” as more influential than any kind of teaching about communication

It’s not as simple as it looks Observational studies of doctors and patients converge on one thing: communication leaves much to be desired  Little exploration of patient values  Active diversion from topics uncomfortable to the doctor --called “blocking”  Inaccurate assessment of patient distress

Patients learn to expect less “He gets really uncomfortable if I talk about dying…I change the topic to baseball.” “Those doctors are bones and tissue, period.” Physicians become ‘providers’ with narrow technical expertise

Physician burnout follows Burnout is  Emotional exhaustion  Depersonalization / cynicism  Low personal accomplishment Physicians reporting insufficient training in communication have higher rates of burnout Br J Cancer 71: 1263 (1995)

Can doctors learn? 160 British oncologists randomized to written feedback vs small group workshop No effect from written feedback Small group workshop resulted in more:  Open questions  Empathic statements  Responded more appropriately to pt cues Improvements persisted at 12 months Lancet 359:650, 2002

What is burnout? A clinical syndrome of  Depersonalization (cynicism)  Emotional exhaustion  Feelings of low personal accomplishment Different than depression because it affects only worklife

Why does it matter? Burnout creates a vicious cycle:  Less investment  Fewer rewards  Feelings that ‘nothing I do matters’  Poorer communication Burnout has a biphasic distribution  Occurs very early  Or late in a career

Burnout and suboptimal care 1. I found myself discharging patients to make the service ‘manageable’ 2. I did not fully discuss treatment options I made treatment or medication errors...not due to a lack of knowledge I ordered restraints or medication for an agitated patient without evaluating them. 5. I did not perform a diagnostic test due to desire to discharge a patient. Ann Intern Med 136:358 + _

What causes burnout? Empirical correlations with  Lack of training in communication  Lack of training in management  Job satisfaction (inverse) High satisfaction may protect against burnout  Example: highly meaningful job, poor working conditions

Stress as a job hazard Eliminating stress—probably not realistic, or even totally desirable, since performance increases with moderate stress Depression and suicide are serious career hazards for physicians

Risk of suicide white male physicians vs white male professionals JAMA 2003;289: Suicide Accidents Stroke Diabetes Cancer Heart HIV Liver COPD Pneumonia

What makes for well-being? From empirical studies:  Relationships  Spirituality  Self-care: intentional balancing  Non-work interests  Physical practices  Work considerations