2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

Buoyancy: A Model for Self-Reflection about
Stress and Burnout in Oncology Providers
Overview: Burnout is a prevalent syndrome among oncology
providers marked by exhaustion, a sense of ineffectiveness,
and depersonalization. This syndrome can have enormous
influence on patient care as well as the provider’s career
fulfillment and personal and family well-being. A buoyancy
BURNOUT IS a familiar syndrome in health care.
Maslach defines it as “a prolonged response to chronic
emotional and interpersonal stressors on the job, and [it] is
defined by the three dimensions of exhaustion, cynicism, and
inefficacy.” 1 It is well described in medical oncologists, 2,3
pediatric oncologists, 4,5 surgical oncologists, 6,7 primary care
physicians, 8 nurses, 9 residents, 10-12 medical students, 13 and
others, including physician leaders. 14,15 Provider burnout
has been associated with varied factors, including higher
workloads, less time with patients, lower experience and
training, young marriages, having young children, lower
reimbursements, higher levels of debt, work-family conflict,
poor health, unrealistic expectations, and anger issues. The
adverse consequences of burnout are not difficult to predict,
and include despair, lower fulfillment, low productivity,
increased turnover, loss of boundaries with patients, increased
medical errors, and suboptimal care. Several excellent
reviews about ways to understand and combat burnout
in oncology have been published. 16,17
The focus of this manuscript is to describe a practical
paradigm for the opposite of burnout: buoyancy. Buoyancy is
a force that keeps one afloat, in contrast to sinking. Posing
this concept as the dependent variable in a multivariable
model, 10 parameters that might be expected to absorb most
of the variance in a model of buoyancy are depicted in Figure
1. They are listed in no particular order, do not have equal
importance within persons or among individuals, and are
expected to vary over time. These theoretical parameters
are: (1) autonomy, (2) exercise of skill, (3) establishing and
maintaining meaningful relationships, (4) being awake to
the present reality (mindfulness), (5) gratitude, (6) courage,
(7) appreciation of impermanence, (8) compassionate mind
frame, (9) finding and keeping one’s sense of safety and
security, and (10) answering the question, “Do I matter?”
The parameters of buoyancy can be compared with one’s
finances, in which the different parts of a portfolio contribute
to the bottom line. For instance, if “managing fear” and
“finding and keeping your safety and security” stocks take a
brief hit, they may rebound splendidly, or perhaps one’s
overall buoyancy will trend upward by virtue of a compensatory
increase in other areas. With this in mind, one can see
how buoyancy would be expected to vary day to day and year
to year. However, a solid manager of the metaphoric portfolio
(i.e., you) could keep the net performance in a consistently
good range and find ways to hedge against extreme
underperformance. Extreme underperformance in buoyancy
would likely manifest as burnout.
A detailed examination of some of the parameters contributing
to buoyancy will reveal how they can manifest and
change over time.
By Michael J. Fisch, MD, MPH
model is proposed as a method to take stock of key parameters
that may contribute to happiness and resiliency. Selfmonitoring
of personal buoyancy parameters may help
oncology providers prevent burnout.
Autonomy (Freedom to Choose)
Oncology providers are well aware of autonomy as an
ethical principle and routinely apply it to medical decision
making. For clinicians, it is worth reflecting on whether one
has a modicum of control over the work environment and
schedule as well as how one proceeds to undertake various
projects. With changes in health care and the trend toward
larger organizational structures, some providers may feel
that they have lost ground in this dimension. It is worthwhile
to consider what has not been lost, to determine which
expectations are realistic, and to have a dialogue and negotiation
with colleagues on key points of autonomy when
necessary.
Exercise of Skill (Doing Your Thing)
This parameter is focused on realizing what one’s
strengths and passions are and making sure one does not
compromise too much in this area. For example, people who
enjoy taking care of patients with complex conditions and
mastering difficult diagnoses would not fare that well in a
high-volume clinic focused on breast cancer survivorship
care. This extends not only to the obvious focus of care but
also to the aspects of work that make it most fulfilling. For
example, the nontechnical, humanistic aspects of work (especially
in settings associated with medical failure) are often
some of the most gratifying experiences. 18 Understanding
that these aspects can be incorporated into one’s focus, while
continuing to build on skills in communication and compassionate
care, can render any patient care setting or individual
encounter more enriching. 19
Early in my career, I received this advice: “Do not let
medical school ruin your education.” Medicine, with its
potentially endless layers, is sufficiently absorbing that it
can overgrow other dimensions of skill and interest if allowed.
Think deeply about your other skills and interests,
perhaps music, reading mystery novels, cooking, boating,
helping others in the community, teaching or coaching
children, martial arts, and so on. Make the opportunity to
exercise skills in some of these areas also. Insights derived
from other realms can help us grow as physicians. Davidoff,
for one, described how music enriches our connection to our
own emotions, sensitizes us to being more empathic, and
From the Department of General Oncology, University of Texas M. D. Anderson Cancer
Center, Houston, TX.
Author’s disclosures of potential conflicts of interest are found at the end of this article.
Address reprint requests to Michael J. Fisch, MD, MPH, Department of General
Oncology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Unit
0410, Houston, TX 77030; email: mfisch@mdanderson.org.
© 2012 by American Society of Clinical Oncology.
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