Is there anything we’re more afraid of?

Imagine this. You’ve been looking forward to your retirement for the last 5 or 10 years, and now you’ve been told that you have metastatic cancer. Or hearing that there’s no effective treatment for your cancer and immediately thinking of your young family. It is simply unimaginable, the devastation wreaked by this condition. And oncologists must bear witness to it all. 

There are certain challenges unique to oncology. Burnout is prevalent, and a huge reason for it is because we have to deal with death quite a lot. Seeing a significant number of patients die over the course of your career does take a toll on people. We must, of course, be very caring and understanding of our patients but if we get too close, we risk burning out completely. So we have to maintain a certain degree of distance, otherwise we wouldn’t be able to cope. But if we distance ourselves too much, we then lack empathy, becoming cold and callous. Take for instance, breaking the news to a patient and feeling utterly crushed by it. You can walk around 3 hours later smitten with pain and grief, or you can go have your lunch. Some might balk at hearing this, but the fact is that oncologists behaving like the former wouldn’t be able to function for long periods. Indeed, it is a balancing act between being empathetic and maintaining distance, and part of an oncologist’s mission is to walk this tightrope well. 

Being a full-time clinician in oncology is, in my opinion, not really sustainable for the long-term and one has a higher chance of burning out. The relentlessness of balancing on that tightrope week after week, seeing a large number of patients and being exposed to powerful emotions constantly, unremittingly, and the routinization of this slightly algorithmic specialty where the recommendations say if A, you do B; if C, you do D, all of that wears people down. You can’t keep doing that, only that for, say, 35 years. Again, you must find your balance, whether that is with your homelife or even with hospital administrative roles. For me, it was with academic work. 

I very much enjoy the intellectual stimulation of working in an academic oncology environment, and am very much interested in the science behind oncology. There have been more changes – revolutionary changes –  in the subject in the last 10 years than there have been since ever, really. And it has shifted the psychology of people working in this field into something much more optimistic. With the development of new immune therapies and new targeted therapies, the prognosis of certain cancers are seeing tremendous improvement. We are at the cutting-edge. And it’s exciting to be a part of this change, and to get to see the improvements happening before your very eyes. But every silver lining has a cloud, and the cloud in this case is the stress of being a medical academic. The currency in academia is one of publications and grants. And so, the pressure of having to produce papers and having your research be fruitful all while being under intense academic scrutiny is nothing to scoff at. Undoubtedly, it is very stimulating work, but the cost of it is you have to achieve results.

A personal practice I’m committed to uphold is to never let patients go without the result of a scan when they come into my clinic for it. There’s always waiting involved for a scan result, but hearing your doctor say “Your scan isn’t reported yet. Why don’t you come back next time for it.” is a shattering blow to a patient. Because they probably haven’t slept the night before, plagued by anxiety; they probably felt sick coming to the hospital, they’ve probably been sitting in that waiting area, tension tightening their shoulders and fear constricting their heart. And the clinicians in their office are not privy to the patients’ emotional turmoil, some might even have no sense of it whatsoever. We are essentially holding the answer to their fate in our hands, and to be so careless with it doesn’t sit right with me.

Ironically, even with experience accumulated over the years, I find breaking bad news to a patient more difficult as I get older. Watching the effect on patients of telling them they’ve got progressive cancer and a limited lifespan is a powerful blow and it does eat at me. But I wouldn’t be so arrogant as to keep going on about the cost to myself, because it’s nothing compared to what the patient and their family are going through. Ultimately, you can do the job of an oncologist well, but there’s never a time that I don’t find delivering bad news a painful experience. And I don’t think one can ever become hardened to it.

It is also never easy when you see failure of treatment and patients going through suffering as a result. Observing suffering is something you can never get used to, and something you cannot avoid in this field. Because you find yourself dealing with patients who progress on cancer, or patients who are expected to do well but don’t, or patients who are doing well but then relapses suddenly. Even for patients who are improving, they are still going through uncomfortable treatments with side-effects, and incredible psychological distress. The truth of it is that stepping foot in an oncology clinic is likely the most traumatic moment of their lives.  

But things are improving, and one shouldn’t do oncology if they don’t possess an optimistic outlook of the subject – that improvements are being heralded in by early diagnoses and better treatments. And an oncologist must also understand that just because a patient is dying doesn’t mean we’ve failed in any way, or that we can’t do anything for them. We can still perform great kindness to temper the devastation of this condition. Besides that, an oncologist can and must find support in teamwork. There’s the palliative care team, the nursing team, the symptom control team, all rallying around the care of a patient. Good colleagues are completely crucial, not just in a clinical aspect, but also as a protective factor against burnout. 

Medicine was a career I was ambivalent about, and nearly gave up on to pursue different subjects. But looking back at my younger self with all his uncertainties, I hope he knows that oncology will prove to be a rewarding and satisfying job for him, and that he will realize, in the future, that it is truly a privilege to be a doctor. Cancer is a scary concept, perhaps the scariest. (Is there anything we’re more afraid of?) But if our patients’ journey is fated to come to an end at the hands of cancer, then it is our duty to walk the remaining path with them, easing their pain and suffering to the best of our abilities as we go along. 

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