I was called to the hospital to see a 26-year-old patient with multiple liver lesions. He had felt well until a few days before his hospitalization, when he presented with abdominal pain. A few days later he was diagnosed with multifocal hepatocellular carcinoma and Child’s class C cirrhosis. I discussed the grim prognosis with the patient, his wife, and 20 of his family members and explained that there were no treatment options available besides supportive care. Shortly after this conversation he was discharged from the hospital and then received support from home hospice services.

My immediate response to this scenario was not too notable, as this was the end of my first year of oncology fellowship and I had encountered similar situations throughout the year. However, I later noticed my response to this and cumulative other events when my 3 year-old daughter lost her balloon out the car window a few weeks later. My response to her tears was simply, “Well, that just happens.” This reaction, with its abundant lack of empathy for what was a significant loss for her, reinforced to me that my clinical exposure to patients can impact my emotional responses to my family and others in my life.

I have attended a number of lectures during training that have discussed the topic of burnout. These thoughtful talks included a list of symptoms, most of which I could recognize in some form or another in myself, and provided suggestions on how to deal with them. I usually left such lectures without any change in behavior on my part, rationalizing, “I will just tough it out.” Often, the major cause of burnout is attributed to the amount of time that we as physicians spend working. After one of these talks, I wondered why the medical field is particularly vulnerable to burnout when so many other careers are prone to long hours as well.

I found a description that partially explains this vulnerability to burnout in 

to Caring for Self While Caring for Others

. The book, written by Laura van Dernoot Lipsky and Connie Burk, has improved my understanding of a process the authors call trauma exposure.

 They define trauma exposure simply as “the fact that we are affected by the suffering of others.” This response to suffering is something I had noticed already, but I ignored its significance until I read their description. As I’ve investigated this further during my clinical rotations, I believe an understanding and dedicated response to trauma exposure is essential to enabling a career of consistent, quality patient care.

Given the abundance of new and difficult situations that oncology fellows face during training, the likelihood of developing symptoms from trauma exposure is high, though it is clearly not unique to the training portion of our careers. While we commit to doing our utmost to relieve the suffering of our patients whenever possible, each emotional episode and undesired outcome that we witness has the potential to cause us to feel that we are primarily responsible for the outcome. During fellowship training, when our knowledge gap is larger and the fear of missing something is greater, this tendency to feel inappropriate responsibility increases proportionally. I believe that an inappropriately high assumption of responsibility for patient suffering contributes to burnout while an inappropriately low level of responsibility is symptomatic of burnout. Our goal must be to remain between these 2 extremes.

Part of the tendency to accept an inappropriate amount of responsibility for patient outcomes is rooted in a belief that suffering occurs for a reason. We may not believe this strongly enough to vocalize it, but I think many physicians utilize this belief for the protection it provides. If we acknowledge that we witness undeserved suffering we must also acknowledge that similar suffering could interrupt our own lives. This realization is difficult, and avoiding it in the short term can be easier than confronting our own vulnerability. A problem that arises with avoidance of this realization is that the emotional distance necessary for this defense weakens our empathy for the patient in front of us; this in turn contributes to decreased job satisfaction and burnout. Therefore, we must develop the skill of acknowledging suffering, recognize our appropriate role within it, and continually care for ourselves in order to sustain our careers in oncology.

When we appropriately handle our response to trauma exposure, our patients benefit and our ability to develop our careers during fellowship is positively impacted. Symptoms of trauma exposure include decreased creativity and motivation, fatigue, and physical ailments, which can delay or limit career choices due to a perceived or actual lack of productivity. Other symptoms of trauma exposure and burnout include a decreased tolerance of ambiguity, a potentially dangerous symptom when premature diagnoses can lead to adverse patient outcomes. Because of its significant impact on clinical, professional, and educational growth, I believe improving our response to witnessed trauma should be a measured goal of fellowship training, prioritized alongside clinical training by fellows and program leadership alike.

I believe the first step in this process, one that has thankfully already begun, is increased recognition of the issue. There is an abundance of published evidence that burnout decreases quality of care and personal satisfaction among physicians.

 Next, we need to improve our awareness of the symptoms of trauma exposure. I have included some of these symptoms in this article, although I do encourage readers to consider further reading in 

. This awareness will enable us to make changes before the symptoms begin to affect our care or our desire to continue in the profession.

In response to trauma exposure, I agree that taking additional time off from work is one potential intervention. However, this option should be reserved only for crisis situations in which immediate, drastic action is required. Similarly, I don’t think that further work-hour restriction is an answer to this problem as it only decreases exposure slightly without teaching the behaviors and skills necessary to sustain a career. While the skills necessary to protect each individual from traumatic exposure are optimal when unique to their practice, I believe some central tenets are helpful to consider.

First, we as fellows need to improve our ability to talk about the fact that we are affected by our patients. This should be recognized as a required skill for excellence in medicine and not a sign of weakness or inadequacy. Preceptors, mentors, and program leaders can teach this skill with something as simple as a short e-mail or comment such as, “That was a tough case today. Good job.” This simple statement acknowledges the significance of difficult cases, communicates the fact that being affected by these situations is universal, and facilitates further discussion as necessary. In my experience, comments like this can have a positive, dramatic impact on my symptoms of burnout without any concurrent change in the intensity of clinical work. Similarly, as trainees I believe we should also start the conversations ourselves with an admission such as, “That was a tough case for me.” This will provide opportunities for mentors to facilitate our growth in this area and potentially their own as well. Because opportunities to discuss difficult cases decrease after training, it is imperative to establish colleagues and mentors who can fulfill this role when fellowship training is complete.

Second, we need to participate in an extracurricular activity completely unrelated to the medical field and our coworkers. Due to the amount of time we spend in the hospital and clinic, it is not an infrequent occurrence for every one of our usual acquaintances to be either a patient or a healthcare worker. When this is the case, it is easy to begin to place everyone in the community into these categories as well. This can contribute to hypervigilance, which during my residency manifested itself as concerns about how best to run a code while in line at the grocery store. Exposure to nonmedical settings and conversations that do not revolve around our patients are therapeutic and are possible even with the most demanding clinical schedule. It is difficult to create this extracurricular time and doing so requires making it a priority while developing clinical patterns that enable this balance.

Recognition of the symptoms of trauma exposure and burnout and the skills necessary to deal with them are very individual. I have a lot to learn about them as well. My hope is that this article serves not as a summation of the entire subject, but as a means for increasing conversation and understanding the topic. There is no easy answer to this challenge. Just as improved therapies are possible when the underlying biology of a disease is understood, I believe that an understanding of the role of trauma exposure in physician burnout will improve our ability to sustain rewarding practice throughout our careers. 

1. van Dernoot Lipsky L, Burk C. Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others. San Francisco, CA: Berrett-Koehler Publishers; 2009.

2. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. 

Matthew Ulrickson, MD, is a second-year hematology/oncology fellow at the University of Washington’s Fred Hutchinson Cancer Research Center in Seattle.

Articles

Burnout is a recurring problem for overworked oncologists and hematologists. This article includes ideas to keep you healthy, engaged, and empathic.

The Biology of Burnout

As fellows, we have all encountered uninsured 

patients in either the hospital or the clinic setting. 

Depending on the type of practice where you are 

training (eg, private vs university, urban vs rural), 

there will be a different proportion of patients who 

lack insurance coverage. According to the Kaiser Commission 

on Medicaid and the Uninsured, in 2009 there were 50 million 

people in the United States under the age of 65 who lacked 

health insurance. In many parts of the country, the stereotype 

of the uninsured homeless patient has been replaced by 

uninsured working families, who now make up more than 

three-fourths of the uninsured population. The increase in 

uninsured patients crosses age and ethnic boundaries and 

affects their health because they are unable to receive both 

the preventive and therapeutic care they need. In the case of 

our patients, the need both emotionally and financially will be 

high if they have a new diagnosis of cancer.

Unfortunately, the number of uninsured patients is 

increasing at a time when the cost of cancer care continues 

to rise. According to the National Cancer Institute, in 2006 

cancer care accounted for an estimated $104.1 billion 

in medical care expenditures in the United States. As we 

develop advanced molecularly targeted therapies, this 

number continues to rise. To an individual patient, there 

is variability in the cost of cancer therapy, but when you 

consider the cost of chemotherapy, surgery, radiation, and 

supportive medications, it’s easy to reach tens of thousands 

of dollars per treatment regimen. For all but the wealthiest 

patients, this becomes cost prohibitive without insurance 

coverage or another means of financial support.

As medical students and residents, we often are able to 

defer insurance status issues to a team of support staff, 

such as social workers and case managers. As we transition 

to attending positions, the issues of insurance coverage 

become increasingly apparent and important to understand 

because of the potential interference in our ability to 

provide excellent care. By understanding the unique 

challenges of the uninsured and the resources available to 

them it is—in most cases&mdash;possible to provide them with 

the same excellent care as their insured counterparts.

Throughout my fellowship, one of the main observations 

was the similar challenges that are faced by patients 

with cancer. Patients of every age, socioeconomic status, 

religion, gender, and insurance status are subject to 

the same disappointments and fears that accompany a 

cancer diagnosis. In addition to similar human emotions, 

uninsured patients have an additional set of worries that 

is unique to this population. An example that has left a 

lasting impression on me during training was a middle-aged 

patient who was battling advanced pancreatic cancer. 

Her poor prognosis and declining health were obvious to 

me, the attending physician, the patient, and her family 

as she progressed through treatment. As we aggressively 

treated her symptoms of pain, nausea, and weight loss, we 

found that we could not treat her biggest worry: losing her 

insurance if she was forced to stop working. Despite her 

symptoms, she continued to work 2 jobs in order to pay for 

medications and maintain her insurance for her family as 

she reached the end of her life. For uninsured patients, in 

addition to the obvious stresses of a cancer diagnosis and 

the effects of therapy, they are burdened with bills that may 

Many patients may feel embarrassed or self-conscious 

about the fact that they cannot afford their medications. 

For example, while rotating through my gastrointestinal 

oncology clinic, I had a patient with locally advanced rectal 

cancer undergoing neoadjuvant treatment with concurrent 

capecitabine and radiation. Despite extensively educating 

this patient on the importance of compliance with twicedaily 

capecitabine, he consistently missed doses. As I 

discussed the case with my attending, I was frustrated 

and angry at this patient, as I felt he had a potentially 

curable cancer but was compromising his care by not 

complying with his medications. My attending was able 

to further explore why he was noncompliant, and the true reason was that he was forced to choose between paying 

for his medications or food for his family. Because he 

was underinsured, he could not afford his medications 

and therefore was rationing them by taking them every 

other day. He was too embarrassed to admit that he 

did not have enough money and was therefore willing 

to compromise his care. This situation could have been 

avoided with better communication with the patient. As 

fellows, we may sometimes feel unequipped to deal with 

these treatment-cost issues and may avoid asking our 

As insurance coverage becomes increasingly more complex, 

we have all learned that some of our best allies in the 

hospital and clinic are our social workers. As fellows, many 

times the responsibility falls on us as the junior members 

of the team to communicate with the social workers to 

ensure that the patient has adequate insurance. There 

Ideally, all patients should receive the same oncology care, regardless of their ability to pay. The reality is often different, as this fellow can attest.

Matthew Ulrickson, MD

Articles

The Biology of Burnout

Caring for Our Uninsured Patients