To hurt and to heal: A cry for better resident self-care

“Please,” I begged my chief resident during intern year. “I need to switch my next rotation. I. Cannot. Watch. Another. Person. Die.”

I did my transitional year internship at a large cancer hospital, where we were responsible for caring for incredibly sick inpatient oncology patients. After a particularly long stretch of inpatient service, I had a sense that a piece of my heart was being ripped out each time I faced another tragic situation, and a growing feeling there wasn’t much heart left. I was scheduled to rotate on the palliative care service next. Not usually one to ask for help, I went to my chief residents and asked for pathology, radiology, or any other rotation that would take me away from patients for a month. In that moment, a wise attending explained to me that the moment I stopped feeling that way when a patient passed was the moment I wasn’t doing my patients justice. She made me a deal: Do two weeks on the service and re-evaluate. “Trust me,” she said.

Two weeks later I realized she was right. On this service, we took time to reflect on the deaths and pain we witnessed. One morning a hospital therapist brought in a guitar and performed music therapy with us. Another morning, we reflected on poetry. Each day, in some form, we talked not only to our patients—and about our patients—but about our feelings in caring for those patients. It seemed a little corny, but not only did it feel better, we were better doctors.

As I moved on and began a radiation oncology residency, the acute pain of actively dying patients was more distant, but the minute daily traumas still added up. The 30-year-old with aggressive inflammatory breast cancer and two kids my daughters’ ages. The 9-year-old who came to her pediatrician for nausea and was diagnosed with disseminated glioblastoma. The 60-year-old schizophrenic, homeless man with the excruciatingly painful basal cell carcinoma devouring his face because he had no family, no resources and no idea how to get medical help sooner.

One particularly painful time on the pediatric radiation oncology service, I spent a day with a 7-year-old boy in his last days of an agonizing and drawn out battle with multiply recurrent leukemia. All he and his mother wanted was for him to make it to his birthday party in three days at his favorite park, which seemed highly unlikely. “How do you do this every day?” I asked my attending. She responded with a sad smile and a half-joke. I went back to the resident room, feeling overwhelmed and, needing some feedback, I settled for a sarcastic comment from an older resident before we both went back to working. Humor, sarcasm, work—all ways we’ve learned to drown the tough emotions this job brings.

Oncologists have one of the highest risks of compassion fatigue,¹ even higher than other cancer center staff,² and compassion fatigue is linked to increased risk of depression, burnout and work-family conflict.³ Studies also show that medical residents are already at higher risk for depression, burnout, and suicidal ideation vs. their age-matched peers.⁴ In fact, suicide is the leading cause of death among male residents, and second leading cause of death among female residents.⁴ I’m not aware of any specific studies in radiation oncology residents, but I can only imagine what this means for us. We are trained to have compassion for our patients. To listen. To ask open-ended questions. To let someone know if we are worried about their mental health.

Residents, with a new academic year recently underway, I ask you to extend those same courtesies to your resident colleagues: Listen. Take care of each other. Check in with a co-resident. Talk about what’s tough. Reach out if you’re worried about a colleague or yourself. Take care of yourself and your colleagues, so we can all take better care of our patients and our families. Hopefully, the references and resources below will help. Program directors and chairs, make it easier to do so. Let’s brainstorm ways to combat compassion fatigue and burnout in our educational programs so we can learn better – it’s time.

References

1. Le Blanc PM, Bakker AB, Peeters MCW, et al. Emotional job demands and burnout among oncology care providers. Anxiety Stress Coping.  2001;14(3):243-263. 
2. Grunfeld E, Whelan TJ, Zitzelsberger L, et al. Cancer care workers in Ontario: prevalence of burnout, job stress and job satisfaction. CMAJ. 2000; 163(2):166-169.
3. Kleiner S, Wallace J. Oncologist burnout and compassion fatigue: investigating time pressure at work as a predictor and the mediating role of work-family conflict. BMC Health Serv Res. 2017;11:17(1):639.
4. Yaghmour N, Brigham T, Richter T, et al. Causes of death of residents in ACGME-accredited programs 2000 through 2014: implications for the learning environment. Acad Med. 2017;92 (7):976-983.