he Buddhist teaching that “Your true work is 

your world and then with all your heart give 

	Medical practice is complex, and we may easily become perplexed and forget our own driving philosophies. The delivery of 21st century medicine is still, at its core, a science and an art. In successful practice, perhaps the application of mindfulness, resilience, and selfcare provide the artist both the canvas and the art.

	Mindfulness is an English translation of the Pali word “sati,”

meaning a simultaneous broad awareness of the present and a narrow focus of attention on the experience.

Mindfulness provides a way of dealing skillfully with what you’re experiencing. Its practice is not about controlling experience but rather allowing space for the occurrences in your life. Some may mistake this concept as the act of focusing away from sadness toward happiness.

	However, more accurately, it is accepting the sadness, placing it in an appropriate compartment, and then choosing to open up the next door.

	Resilience explores how we adapt to change and respond to difficult experiences.

In practice, this allows us to recover in a way that sustains our ability to be present in the future without fear of our past. Some methods of resilience incorporate positive engagement in the midst of the stress, while mindful understanding of the experience allows one to learn and grow from these experiences.

	Stress is inevitable in medicine, and the practice of oncology brings with it a host of emotions. Mindfulness-based resilience acknowledges that it is normal to feel these emotions.

	Ideally, we receive training in the science and art of practicing medicine, but rarely do we learn to incorporate the skills that allow for adaptation to the stressors inherent in the doctor-patient relationship. It is then that resilience is born.

	As individuals, team leaders, and patient advocates, a multitude of stressors arise from internal and external sources to challenge us. Over the course of a busy clinic day, many competing goals may lead us to feel overwhelmed and detached from the task at hand. Unexpected patient changes or emotions may arise in the context of a clinic visit and sap our energy. Family or interpersonal concerns may play a role in the day-to-day experience. As we move from appointment to appointment, we can better serve our patients by allowing time to recognize the unique constructs in each relationship, patient visit, and role we play as physicians. There will be times when our patients merely need us to listen to the burdens of coupling a chronic illness with the business of daily life. As physicians, our challenge is to maintain compassion while standing steadfast in the gap between work and home, thereby garnering the strength and resolve to meet the next patient with the same novelty. To meet these challenges, techniques in self-care serve us well through the consideration of mindbody interventions, self-awareness, and preservation, as well as understanding the difficulties in coping with loss, burnout, and depersonalization. It is important to maintain work-life balance. Applying daily rituals allows pause for reflection and transition and functions to sustain our lifelong practice as caregivers.

	Mindfulness and meditation have been, and continue to be, studied in cancer, primarily to measure outcomes related to pain control, anxiety reduction, and an enhanced quality of life.

Perhaps the application of this broader science has, at its core, a place for the provider as well.

	Canadian physician William Osler once implored physicians to “throw away all ambition beyond that of doing the day’s work well. The travelers on the road to success live in the present, heedless of taking thought for the morrow.

	Live neither in the past nor in the future, but let each day’s work absorb your entire energies, and satisfy your wildest ambition.”

To truly focus on the task at hand is difficult, as it relies on tuning out the distractions that frequent the clinical day. The application of mindfulness, resilience, and self-care allow a means to learn our own tendencies so that we can better communicate with patients and ourselves.

	As we progress on this journey, it is helpful to understand what drives our reactions. These may be referred to as “hooks,” and represent the things that trigger our emotions. It takes courage to be honest and understand why a particular event or experience might be so disheartening. Through identifying our hooks, we become more aware of our active reactions and learn how to analyze, grow, and adapt to be able to give full attention to the present situation.

	Everyone has a story, and as a physician you want to get to know those stories, including your own. Exploring what our triggers are, as well as what constitutes our sense of happiness, is a means of better understanding ourselves.

	Likewise, self-care is emerging as an important component of a healthy practice. For some, this may require introspection to understand what is required for one’s own happiness or wholeness.This understanding is gaining formal credence in major medical centers. Many programs have incorporated creative therapies such as visual arts, dance, and music to help individuals express their feelings and cope with the demands of the care continuum. A mindful communication program developed for physicians was studied and found to be associated with increased sense of well-being and attitudes associated with patient-centered care.

Self-care rounds, or Schwartz rounds as they have become known, provide a regular opportunity for providers to openly and honestly discuss social and emotional issues that arise in caring for patients.

In contrast with the science discussed during traditional medical rounds, the focus is on compassionate care through the human dimension of medicine.

This is particularly meaningful for cancer providers, caregivers, and physicians alike. Insomuch as we take care of ourselves, we are able to give more openly and freely to others, our patients, and our community.

	While today’s medical students are more schooled in communication than their forebears, there are still very few opportunities to learn about the death and dying process one is sure to encounter very early on in this field. To some, it may be seen as a rite of passage to learn how to talk to those who are dying and their caregivers (ie, the birthing of an oncologist).

	Today, we understand that there is more of a science to this. A mindful practice and understanding of our own emotions can prepare us to be better communicators for our patients and their families. Few would deny that there is an element of fear in coming to the end of one’s battle, whether it be the patient’s, the caregiver’s, or the physician’s. And

	while we all strive to achieve different goals, we do each sheepishly desire the best of possible outcomes.

	Caring for critically ill and terminally ill patients can elicit many emotions, including fear, grief, fatigue, and sense of failure, all of which may contribute to a sense of burnout.

These emotions can be particularly difficult in relational constructs, including instances where physicians develop close bonds with patients and their families. It is at this time that reflection becomes important. Ask yourself,

	“Why is this difficult?” Give yourself room to acknowledge the meaning before allowing yourself to come to “terms” with the passage of time that occurs in all of our patients’ care timelines.

	As physicians, we may experience an additional sense of grief due to our inability to control the situation and thereby prevent patients from experiencing physical or emotional suffering, which further portends an inner sorrow on the part of the physician.

	The intentional application of techniques that recognize the active experience and provide adaptations and room for self-reflection benefits us both personally and as a medical community. In the case of patient loss, many physicians may feel it is unacceptable to talk about, much less experience or acknowledge, this difficulty in oneself. Oftentimes, there is a stigma around death and dying, viewed as the culmination of several failed attempts at competing with the cancer itself. Nevertheless, patients and families demand an everpresent physician capable of leading the experience even when the experience becomes extremely difficult. For young cancer physicians, this may feel like charting an unknown course, and in many respects it is best navigated personally with introspection and understanding.

	There are ever-changing sets of interests in the delivery of modern medicine. More than ever, today’s doctors are charged with delivering medicine with precision, in a cost-constrained environment, with a high level of patient satisfaction.

As oncologists, we recognize that for each victory there will be many defeats. Each of these aspects of training and practice in and of itself surely contributes to the burnout rate of physicians and oncologists alike. While we struggle to find new and better ways to deliver cancer care, the loss of many of our patients with advanced cancer, coupled with the constraints of more tightly regulated health systems, may lead to depersonalization.

	The frequent needs of a challenging patient require a progressive level of compassion and understanding. Clearly, even the most empathetic provider can easily fall to a level of compassion fatigue. Understanding what brings meaning and enjoyment to one’s life and medical practice allows for interpretation of even a challenging experience within a positive construct. Moreover, this understanding of meaning, more so than the removal of the components of dissatisfaction within the work construct, has been linked with improved sense of fulfillment.

	Burnout is a commonly reported outcome among medical oncologists, with studies suggesting a prevalence of 25% to 35% among medical oncologists. There is growing evidence that physician distress can impact not only quality of care but also interpersonal relationships.

Furthermore, a recent article in the Journal of Clinical Oncology describes the worklife-balance satisfaction of oncologists as lower than their peers’. New fellows have reported a burnout rate as high as 43%, even with fellows underestimating the hours spent on patient care at work and at home.

	I’m sure we all can recall the first and the last time we divulged to anyone that we were, indeed, oncologists. Commonly we notice that shrug that says “I pity you,” and the tone in their voice when someone comments “That’s a tough job.” No one needs to tell you it’s a hard job. Most of us chose this job understanding its challenges and rewards. However, for me it was still an enigma yet to be realized: the everyday difficulty of turning off work and turning on home, of embracing the present, saying no to sadness, and saying yes to happiness.

	For many of us, our support system is tied closely to our relationships outside of work (eg, spouses and other family members). Leaving work at work may prove difficult when such heavy decisions are weighing on your mind. Relationships are an important part of the medical experience. As physicians, our ability to feel connected is central to our professional and personal identity. However, our relationship partners may feel unprepared to cope with the enormity of emotions that develop through providing this type of care.

	When I was a child, there was a proverb posted on a wall in my home that read “Change the things you can and accept the things you cannot change.” Recently, I have come to a better understanding of this as a daily task. Rituals are a hallmark of both mindful and resilience-based practice. One may consider hand washing between patients a ritual of sorts, and an opportunity to pause and reflect.

	This intentional use of rituals may offer a transition from one space to another; wholly allowing you to engage, adapt, and learn, while providing newness to the many important and changing relationships in your life. When I began my fellowship, I had a multitude of advice bestowed upon me, perhaps the strongest of which echoed the theme of providing a boundary between work life and home life. And while I still find this difficult, there is something to be said for the pause that occurs when you exit the building to go on to the enjoyable and calm environment we each call home.

	As a vital element of our work, oncologists provide support and direction to others during a difficult time. As an imperative, we must fill our own pool so that we will be able to give to others. Mindfulness is about being present in the moment, acknowledging who you are, and accepting what’s going on, while absolving yourself and the situation of judgment. Resilience incorporates an understanding of meaning, relationships, acceptance, compassion, and reflection. Intentionality drives us to deliberately seek connections with patients and people around us. Self-care reminds us to renew the strength that propels our journey. Coupled together, these entities make us present and purposed in our effort to provide wholly centered care that delivers the best for our patients and providers, therein building a community of care.

			Osler W. The Army surgeon. In: Aequanimitas: With Other Addresses to Medical Students, Nurses and Practitioners of Medicine. Philadelphia, PA: P. Blakiston’s Sons & Company; 1904.

			Buddha quotes. Thinkexist.com website. http://thinkexist.com/quotation/ your_work_is_to_discover_your_world_and_then_with/200312.html. Accessed October 6, 2014.

			Gunaratana BH. Mindfulness (Sati). In: Mindfulness in Plain English: Updated and Expanded Edition. Boston, MA: Wisdom Publications; 1996.

			Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-1293.

			Grossman P, Zwahlen D, Halter JP, et al. A mindfulness-based program for improving quality of life among hematopoietic stem cell transplantation survivors: feasibility and preliminary findings [published online October 10, 2014]. Support Care Cancer.

			Eyles C, Leydon GM, Hoffman CJ, et al. Mindfulness for the self-management of fatigue, anxiety, and depression in women with metastatic breast cancer: a mixed methods feasibility study [published online August 26, 2014]. Integr Cancer Ther.

			Malboeuf-Hurtubise C, Achille M, Sultan S, Vadnais M. Mindfulness-based intervention for teenagers with cancer: study protocol for a randomized controlled trial. Trials. 2013;14:135.

			Forsyth JP. Developing comfort with your judgmental. In: The Mindfulness and Acceptance Workbook for Anxiety: A Guide to Breaking Free From Anxiety, Phobias and Worry Using Acceptance and Commitment Therapy. Read- HowYouWant.com; 2010.

			Goodrich J. Compassionate care and Schwartz Rounds: the nature of the work--acknowledging it is hard. Nurse Educ Today. 2014;34(9):1185-1187.

			Schapira L, Blaszkowsky LS, Cashavelly BJ, et al. Caring for one of our own. Oncologist. 2014;19(5):545-549.

			Shanafelt T, Dyrbye L. Oncologist burnout: causes, consequences, and responses. J Clin Oncol. 2012;30(11):1235-1241.

			Abernethy AP, Grubbs SS. Managing cumulative expectations in oncology: challenges and potential solutions. Am Soc Clin Oncol Educ Book. 2014:e140-e144.

			Shanafelt TD, Raymond M, Horn L, et al. Oncology fellows’ career plans, expectations, and well-being: do fellows know what they are getting into [published online July 21, 2014]? J Clin Oncol.

Articles

The Buddhist teaching that "Your true work is to discover your world and then with all your heart give yourself to it" can certainly be applied to oncology.

By Brenda Ernst, MD

Articles

Mindfulness Based Resilience and Self-Care: Why it Matters in Oncology