2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

BUOYANCY TO PREVENT STRESS AND BURNOUT
to get almost all of your needs met by trying to help others
and neglecting yourself? Do you find yourself being cynical
or intolerant of “fools,” catastrophizing, or being overly
negative or pessimistic? Self-appraisal in these realms is
healthy. We learn about the concept of “equipoise” in clinical
trials and scientific experimentation, but it is equally critical
to introduce equipoise in our own ways of looking at things.
In other words, learn to resist becoming too enamored of
your own ideas and perspectives. Take a close look at your
position about an issue and think, “Maybe so.” Next, try to
explore alternate perspectives, ranging from one extreme to
the opposite and then back toward your own estimate of
reality. You may end up in the same place—your position—
but flexing your mind around an issue can help you find
greater balance and enhance your buoyancy.
Gratitude
The idea that it is healthy to “count one’s blessings” is
widely understood. However, having the discipline and skill
to maintain this particular intention is not simple. One way
to accomplish this is to think deeply about the concept of
buoyancy and notice that there are indeed things that are
working in your life. As a further step, having noticed your
buoyancy and its roots, take a moment to actually feel
gratitude for achieving balance. Finally, act on gratitude by
speaking or writing words of appreciation. In my practice,
good habits are often easiest to internalize when I implement
them at a patient’s bedside for the purpose of improving
patient care. In that setting, start by noticing and
appreciating elements of your patient’s behavior. Patients
do amazing things all the time; it is not difficult to find
behaviors to comment positively about. Learning to say
goodbye to patients toward the end of life 23 and writing
letters of condolence to family members 24 are examples of
showing gratitude in clinical settings. The next step would
be extending this practice to your colleagues, staff, family,
and friends by saying “thank you” more frequently. Many
providers are surprisingly stingy when it comes to saying
“thank you” in professional and personal realms, perhaps as
a result of high expectations from staff and colleagues.
Expressing gratitude more often does not require lowering
expectations, and it can help bolster buoyancy.
Courage (Managing Fear)
Oncology providers, in general, have a great deal of
courage. It takes courage to compete in school and achieve
enough success to get trained in medicine and cancer care. It
takes courage to deal with the sacrifices inherent in medicine
and the great responsibility (and privilege) of caring for
persons who are ill. But courage is not generic. One can be a
war hero and be frightened of snakes or bugs. If you think of
courage as “fear management,” then it makes sense that one
can be successful in some realms and still need work in
others. To guard against burnout and build buoyancy, providers
need to learn how to recognize their fears, give those
fears a name, and reflect deeply on how to confront fear.
Common fears include fear of making mistakes, being
blamed or sued, or being judged or taken for granted by
colleagues, friends, or family. There may be fear of losing
income as a result of competition, of not being appropriately
recognized or promoted, or any number of other concerns
that are understandable in our modern environment. Other
issues revolve around countertransference and one’s feelings
about personal mortality and death. Becoming aware of our
fears and developing habits and action plans for managing
them is critical. Introspection is critical. For many providers,
connecting with others is preferable to tackling these
tasks alone.
Appreciation of Impermanence
To appreciate impermanence is to understand that all
things change and that loss is part of the package in life.
Being flexible and open to change is essential for personal
growth and equanimity. I may not relish change in all
instances (like my aging body or my changing bank account),
but I can see this truth. The idea that change is the nature
of all things is yet another topic that is easy to recite but
difficult to integrate on a practical level. Change is frequently
associated with emotions, both positive and negative.
People cry at weddings and funerals and graduations,
for instance—all events associated with transitions. How
often to you notice your own emotions? Do you notice when
you are getting angry? Are you aware of your own grieving?
In oncology, dealing with loss and grief is particularly
important. 16,25 In his classic article “Dealing with Our
Losses,” Balfour Mount wrote, “To live is to experience
loss.” 26 A mentor once told me, “You have got to learn how to
lose.” We experience loss not only with our patients facing
serious illness but also with changes, setbacks, and failures
of every variety: experiments that fail, grants not funded,
papers not accepted, organizational shifts that are not in our
favor, and the list goes on. As oncology providers, we should
strive to maintain our resilience while at the same time
finding a way to notice and manage our emotions. Although
people are variably resilient, there are related skills that can
be learned and practiced. Mindfulness training, for example,
has shown benefits for helping physicians become more
awake to their present reality as well as positioned to accept
the inevitability of change. 8
Compassionate Mind Frame
It is a bit embarrassing to have been concerned with the
human problem all one’s life and find at the end that one
has no more to offer by way of advice than ‘try to be a little
kinder.’ –Aldous Huxley
I think about compassion as something that starts with
empathy but requires buoyancy (like a coenzyme in a chemical
reaction) to come to fruition in an objective way. Without
buoyancy, empathy would pull one toward the same place
as the subject of one’s empathy. The good news, then, is that
all the things you do to stay buoyant position you for success
in creating and maintaining a compassionate mind frame.
The aspect of compassion that takes particular practice and
attention is empathy. Once again, a good place to start is
in the clinical realm—learning to act empathetically toward
your patients and, better yet, to feel empathy, too. There
are good reviews on this topic, 27,28 and communication
workshops and time spent with master clinicians can help
promulgate this skill. The next step toward maximizing
the buoyancy derived from a compassionate mind frame is to
extend these skills outside the clinical setting to staff,
colleagues, students, family, friends, and strangers, and
then stretch this powerful mind frame all the way to oneself.
Being compassionate toward oneself is a beautiful way to
stay resilient and guard against the forces of burnout. A
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