On Being An Oncologist

ON BEING AN ONCOLOGIST

byWalter F. Baile, M.D.Robert Buckman, M.D., Ph.D.

Reflections on the Personal Dimensions of Clinical Oncology

A Workbook Companion to the Video Presentation by Megan Cole and William Hurt

2nd Edition

The University of Texas MD Anderson Cancer Center Program on Interpersonal Communication AndRelationship Enhancement (I*CARE) Presents:


byWalter F. Baile, M.D.Robert Buckman, M.D., Ph.D.

Reflections on the Personal Dimensions of Clinical Oncology

A Workbook Companion to the Video Presentation by Megan Cole and William Hurt

2nd Edition

The University of Texas MD Anderson Cancer CenterProgram on Interpersonal Communication And Relationship Enhancement (I*CARE)

Please go to www.mdanderson.org/icare to view “On Being An Oncologist.” If you are applying for CME credit, please enter through the “Earn Free CME Credit Online” link.

This program can be viewed at our Web site: http://www.mdanderson.org/icare or by purchasing the DVD.

Continuing Medical Education (CME) Information: To obtain 3.00 AMA PRA Category 1 Creditstm, you must complete and submit the registration, post test and evaluation found on pages 48-55.

Accreditation/Credit DesignationThe University of Texas MD Anderson Cancer Center is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The University of Texas MD Anderson Cancer Center designates this enduring material for a maximum of 3.00 AMA PRA Category 1 Creditstm. Physicians should claim only credit commensurate with the extent of their participation in the activity.

This enduring material has been designated by The University of Texas MD Anderson Cancer Center for 3.00 AMA PRA Category 1 Creditstm in medical ethics and/or professional responsibility.

Release Date: May 1, 2011Expiration Date: May 1, 2012

NOTE: The content of this educational activity is reviewed annually. After May, 2012, please call the Department of CME/Conference Management at The University of Texas MD Anderson Cancer Center (713) 792-5357 for verification of the status of continuing medical education credit for this program.

Target AudienceThis enduring material will be of value to oncologists, nurses, PAs, trainees (fellows, interns, residents) and other health care professionals.

Goals• Tocreatepositivechangesinphysiciancompetenceinrelationtocommunicatingwithpatients;• Topromoteandfosterdiscussionsaboutavarietyoftopicsrelatedtothedemandsoncologyplacesonthoseinclinicalpractice, especially personal burdens • Toimprovethementalhealthstatusofoncologyprofessionalsinregardtodealingwithemotionsandburnoutbylearning coping mechanisms • Professionalgrowth

Educational ObjectivesAfter participating in this enduring material, the participant should be able to: • Identifydailydilemmasandstressorsinvolvedinoncologyclinicalpracticethatmaynegativelyeffectdoctor/patient communication (knowledge)• Moreopenlydiscussfeelingsoffrustration,inadequacyandburnoutwithoutfeelingashamed,therebymakingthesefeelings/ stressors less noxious (knowledge)• Developnewanddifferentcopingstrategies,newinsightsandnewpersonalresources(knowledgeandcompetence)• Distinguishthatthesefeelings/emotionsarenormaland,throughacceptanceofthis,beabletomovefromtherealmofbeing stressful to the promotion of professional growth (knowledge and competence)

© 2002, 2011 2nd edition, The University of Texas MD Anderson Cancer Center. All rights reserved. No part of this work can be reproduced, distributed or otherwise used without the express permission from The University of Texas MD Anderson Cancer Center.

All statements and opinions contained herein are solely those of the individual speakers and may not reflect those of The University of Texas MD Anderson Cancer Center.

The University of Texas MD Anderson Cancer Center Disclosure Policy for Program Chair(s), Planning Committee Members, Teachers, or Authors and CME Activity Reviewers

The Accreditation Council for Continuing Medical Education has announced standards and guidelines to insure that individuals participating in CME activities are aware of program chair(s), planning committee member, faculty/teacher/author, CME activity reviewer relationships with commercial interests that could potentially affect the information presented. The University of Texas MD Anderson Cancer Center has implemented a process whereby everyone who is in a position to control the content of an educational activity must disclose all relevant financial relationships with any commercial interest.

The University of Texas MD Anderson Cancer Center has resolved all conflicts of interest prior to this activity. For information on this process, please contact the Department of CME/Conference Management at 713-792-5357.

On Being An Oncologist - MEMV 1107

Faculty/Program Planning Committee Members/CME Activity Reviewers/Approvers Disclosure of Relevant Financial Relationships

Faculty/Program Planning Committee members and CME activity reviewers/approvers that have indicated no financial interests, arrangements or affiliations. Faculty have indicated no financial interests, arrangements or affiliations and presentations will not discuss investigational or off-label uses of a product:

Walter F Baile, M.D.Robert Buckman, M.D., Ph.D.Emil J Freireich, M.D.Rhonda Prescott KirbyCathy Kirkwood, M.P.H.Gregg Staerkel, M.D.Stephen P. Tomasovic, Ph.D.

Faculty/Program Planning Committee Members/CME Activity Reviewers/Approvers Disclosure of Relevant Financial Responsibility that have financial interests, arrangements or affiliations:

Christopher G. Wood, MD

Grantorresearchsupport:Pfizer,Agenus;Paidconsultant:Pfizer,Argos;Speaker’sBureau:Pfizer,Argos;Honoraria:Pfizer

To obtain AMA PRA Category 1 Credittm for this activity, complete the Registration Form, Evaluation, and Post-Test and send or fax to:

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For questions about this program, please contact:Cathy Kirkwood, M.P.H., Project DirectorDepartment of Faculty DevelopmentInterpersonal Communication And Relationship Enhancement (I*CARE) ProgramThe University of Texas MD Anderson Cancer CenterP.O. Box 301402, Unit 1426Houston, TX 77230-1402Email: [email protected]

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TABLE Of CONTENTS

Background & Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . .1

The Personal Demands of Clinical Oncology . . . . . . . . . . . . . .3

Time Pressures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Communication: Seeing the Person through the Patient . . . .11

Breaking Bad News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

The Angry Patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Hope & Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Sympathy, Empathy & Personal Boundaries . . . . . . . . . . . . . .27

The Dying Patient & the Physician . . . . . . . . . . . . . . . . . . . .31

How to Cope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

In Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

Appendix I: S-P-I-K-E-S Communication Protocol . . . . . . . .39

Annotated Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

Continuing Medical Education. . . . . . . . . . . . . . . . . . . . . . . .48

CME Registration & Answer Sheet. . . . . . . . . . . . . . . . . . . . .49

CME Post Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51-52

CME Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53-55

The oncologists who participated in our focus groups Megan Cole and William Hurt for theirgracious gift of time and talent

Robert C. Bast, M.D.Vice President, Translational ResearchDiane C. Bodurka, M.D.Professor, Gynecologic OncologyStephen C. Stuyck, M.P.H.Vice President, Public AffairsJo Ann Ward, M.P.H.Associate Vice President, Public AffairsStephen P. Tomasovic, Ph.D.Senior Vice President, Academic AffairsRobin Sandefur, Ph.D. Past Executive Coordinator of Faculty Development & ResourcesJanis Apted, M.L.S.Associate Vice President, Faculty DevelopmentJohn Mendelsohn, M.D., President, The University of TexasMD Anderson Cancer Center and Anne Mendelsohn for their vision and support.

Sunni Hosemann, B.S.N. Program Education Coordinator, Academic AffairsTelehealth Services1st EditionCathy Kirkwood, M.P.H. Project DirectorFaculty Development2nd Edition

Greg West, Director of ProductionUT Television

Beth NotzonProgram Manager, Division PublicationsRadiation Oncology andJulia M. StarrFormer Scientific EditorDepartment of Scientific PublicationsEli GukichBook DesignCommunications OfficePrinting by UT Printing & Media Services

Walter F. Baile, M.D.Professor, Behavioral ScienceDirector, Interpersonal Communication And Relationship Enhancement (I*CARE)Department of Faculty Development

Robert Buckman, M.D., Ph.D.Medical Oncologist,Professor, Department of Medicine,University of Toronto\Princess Margaret Hospital, Adjunct ProfessorDepartment of Behavioral ScienceMD Anderson Cancer Center

© 2002, 20112nd EditionThe University of Texas MD Anderson Cancer Center

We gratefully acknowledge

Special thanks to

Project Coordinators

Video Production

Book Production

Project Directors

BACkGrOuNd & INTrOduCTIONThe video On Being an Oncologist had its beginnings when Megan Cole, star of the play WIT, and several members of the staff at The University of Texas MD Anderson Cancer Center led a series of focus groups made up of faculty and staff to talk about what it means to be an oncologist. Group discussion focused on the personal aspects of being an oncologist—the demands, the burdens, the rewards, the emotional costs. The video comprises extracts from those discussions, dramatized by Megan Cole and William Hurt.

The aim of the video and of this workbook is to promote and foster discussions about a variety of topics related to the demands that oncology places on all of us in clinical practice, in particular the personal burdens.

Those of us who worked on this project—and probably you as well—have felt that the psychological needs and burdens of patients with cancer and of their family and friends place a particularly heavy load on the clinical team. Furthermore, this burden and its psychological tolls, including the feelings of frustration,inadequacy,andevenburnoutandthemanyotheremotions that we all experience from time to time, have not been comfortable subjects for discussion.

The problems that accompany the job of caring for people with cancer have, of course, many features in common with clinical care in other disciplines. However, they are intensified and augmentedbyourpatients’feelingsandfearsaboutthediagnosisand by the social and personal attitudes and anxieties related to the word “cancer.” In addition, our current social attitudes toward serious illness and the topics of death and dying are always present in the background, making the atmosphere yet more difficult. Even though some of these factors have their beginnings long before the physician and the patient meet for the first time, they may still negatively influence doctor-patient communications, making the practice of clinical oncology more difficult.

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For those reasons, clinical oncologists are more likely than clinicians in other disciplines to feel distressed, frustrated, angry, saddened, and even depressed and sometimes apathetic or burnt out. At the same time, oncologists often feel that they“shouldn’t”beexperiencingthesefeelings,andtheymayeven feel ashamed or worried about their own emotions and emotional stability.

We hope that by airing some of these issues with the video and the workbook we will encourage reflection and more open discussion of the personal aspects of oncology care. We also hope that thinking about and discussing these issues will encourage the development of new and different coping strategies and that the discussions will lead to new insights and provide new personal resources.

USING THIS PROGRAMThis program may be used by individuals on their own, but we also envisioned it as a teaching and mentoring tool to be used in group discussions or even workshops. A suggested format: view the videotape in segments, stopping after each Focus Group Topic for reflection and discussion, and using the topicquestionsprovidedoryourownquestionsorreflections.Encourage group members to write or share their own experiences and discuss their thoughts and feelings. Please read the Background and Introduction section before you begin.

THE PErSONAL dEMANdS Of CLINICAL ONCOLOGYTaking care of patients with life-threatening illnesses is a stressful experience for all of us who daily face not only the medical challenges of providing effective treatments, but also the psychological burdens imposed by patients and their own emotional reactions. Responding to patients who are desperate for cure, who may be disappointed or angry about their care, or who are unable or unwilling to face the reality of a dire medical situation puts unusual demands on oncologists.

Cancer care also has a significant impact on the inner life of oncologists, who must deal with their own strong emotions connected with patient care. They may have feelings of grief thatcanemanatefrompatientloss,asenseofinadequacy,andeven a feeling of self-blame when they feel that there are other things that could have been done for a patient. They may also be angry at colleagues who seem to be delivering less than optimal care, they may have difficulties negotiating closeness with patients, they may be frustrated at not being able to spend enough time with patients, and they may have many other emotions.

Unfortunately, these emotions, while very common among cancer practitioners, are rarely acknowledged and may often linger outside the awareness of clinicians who are not trained to examine the sources of their distress or troublesome feelings. They are often treated as the “price one pays” for taking care of very ill patients. It is also ironic that, while physicians readily acknowledge the emotional burdens of having cancer and encourage their patients to participate in support groups and other activities to assist in coping, they often ignore the emotional burden of being a cancer physician and rarely discuss the stresses they experience.

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The medical literature is beginning, however, to acknowledge theconsequencesofthesestresses,notonlyonthephysician’spersonallifebutalsoonpatientcare.Whatistheconsequenceonthephysician’sfamilylifeoflonghoursworkedintheclinic?What impact does repeated patient loss have on the morale ofthedoctor?Howdoesaphysicianmaintaina“therapeuticboundary”withpatients?Howdoesaphysiciancopewithfeelingsofnothavingdoneenoughtohelpapatient?

Theseareallvalidandlegitimatequestionsthatdeservetobeexplored. When they remain foci of stress for the physician, they can result in demoralization, withdrawal from the patient, a cold and detached attitude in delivering patient care, the offering of unrealistic hopes to patients, an inability to discuss end-of-life care with patients, the hiding of negative information from the patient, and ultimately depression and burnout.

The series of dramatized dialogues on the video are meant to illustrate the daily dilemmas and stresses of caring for cancer patients. They are intended to create awareness and promote discussion of the feelings, frustrations, difficulties, and also the joys of being a cancer doctor. Psychiatrists and psychologists have known for many years that the acknowledgment and discussion of stresses can make them less noxious. By identifying feelings and exploring their source, clinicians can come to accept them as normal, and these emotions can move from the realm of being stressful to actually promoting professional growth.


“I’m constantly behind and constantlypressured by being behind”

Focus Group Topic #1

TIME PrESSurESThe sense of never having enough time to spend with patients is a common feeling among cancer doctors.

Comments from the members of the focus group must seem familiar to you and will doubtless raise memories of similar situations and of many others. As the old saying has it, “we always seem to leave the clinic too early and to get home too late.”

Outside forces such as managed care, the demands of academia, thedocumentationandpaperworkrequired,andinformedpatientsandfamilymemberswithmanyquestionscanbeoverwhelming. Even though progress has been made inreducing the mortality of cancer, the low rate of cure of many of the solid tumors makes it easy for us to feel that we have failed or are ineffective and that perhaps we could achievemore if we worked harder or did more.

Arethosefeelingsfamiliartoyou?Doyoufeelthatthatisafactororadimensionofthefeelingoftimepressure?

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Scheduling conflicts Needy patientsLong hours Never enough time

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TIME PrESSurESTopics for Discussion

Howprominentislackoftimeinyourlistofstressors?Wheredoesitrankamongtheotherstresses?Howmanytimesduringthedayareyouacutelyawareoftimeconstraints?

Can you recall a recent episode where you might have wanted or needed to spend more time with a patient and felt badly that youdidn’t?

When you are trying to do too much in too short a period of time,areyouawareoffeeling“overloaded?”Areyoueverawarethat when time pressures increase you get physical symptoms suchassweating,tachycardia,drymouth,queasiness?Whenunder time pressures, do you ever become irritable or annoyed atothers?

Howproficientareyouinmanagingyourtime?Whatfactorscanyouidentifyinyourownfeelingoftimepressure?

Is the sense of time pressure worse at any particular time—at thestartoftheweekorattheendofit;onreturningfromaholidayortripoutoftown?

Doyoueverfeelbadlybecauseyoudon’tspendenoughtimewithpatientswho“reallyneedit?”

Are there situations in clinic or ward rounds that do NOT makeyoufeelrushedortime-constrained?

Is there anything you could do to make other activities more likethat?

What activities, such as academic activities or research, make youfeelleastrushedorpressured?

Doyoutakeyourworriesaboutyourpatientshomewithyou?

Whataresomewaystoimprovethesituation?

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NOTES

“... there’s a little bit of that person’s life that kind of escaped… it humbles you”

“When I was a student I had no idea how to talk to patients about medicine”


COMMuNICATION: SEEING THE PErSON THrOuGH THE PATIENT

Acknowledging the person and the personality of your patient is a major component of the doctor-patient relationship.

Communication is not just another task, not just “another part of the job you have to do,” it is an essential component of the relationship between you and the patient and affects their perception of you and the effects of the treatment. Of all aspects of communication in oncology care, perhaps the most importantisacknowledgingthepatient’semotionalstate.Inthat way the person who is your patient becomes more visible, and that actually makes things easier, not more difficult.

Communication skills may reduce your stress, facilitating both the support of the patient and the management of the medical condition.Understandingthepatient’sfeelingsandconcernscanprovideauniqueperspectiveonthepatient’smotivationand decision making, as is illustrated in the scenarios. They show how an appreciation of the personal component adds insight and may help the task of providing care.

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Understanding quality of life When no decision is a decision

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Topics for Discussion

How much time on average do you spend getting to know yourpatientsindividually?

What percentage of your patients do you think you know well aspeople?

Does knowing a patient well hinder or help your clinical management?

Do you think that patients value your attempts to get to know thempersonally?

Haveyoueverbeenconcernedthataskingpersonalquestionsof your patient would be intrusive, take up too much of your time,orfeeluncomfortable?

Whatquestionscouldyouaskthatwouldhelpyouknowyourpatientbetter?

Howdoyourpatientsreacttouncertainty?

How do you frame information about treatment, risks,andprognosis?

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NOTES

“There’s no nice way to say ‘brain tumor’…”

“People know when they’re being lied to…”

“…they’re not going to be patronized”


BrEAkING BAd NEWSGiving bad news is one of the most frequent, yet stressful tasks that an oncologist must perform many thousands of times over the course of a career.

While patients have a right to information about their cancer, this never makes the task any easier. For many reasons, giving bad news can evoke strong feelings in the doctor (and the patient) that can sometimes sabotage the interview or cause communication to break down, resulting in avoidance of the discussion of negative information or a poor understanding on the part of the patient.

Even though many patients today are well-informed, still it can be a dilemma to determine how much information to give the patient and how to give it. Many families also now want to participate in the care of the patient with cancer, making information sharing sometimes very complicated. Strategies and plans for communicating in difficult situations can help. An example is the “S-P-I-K-E-S” protocol that is summarized in Appendix I.

All of the situations described in this section of the video were clearlydifficultandawkward.It’simportanttorealize,however,that the difficulty originated in the diagnosis itself and in the way the patient handled the information. Perhaps a key phrase here is,“There’snonicewaytosaybraintumor.”Althoughstrategies(such as S-P-I-K-E-S) will help reduce the discomfort for both the patient and physician, they cannot remove the shock altogether. It is important to realize that and not to expect too much from theuse of a strategy or plan.

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My mother is not to be told Patients’ rights

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BrEAkING BAd NEWSTopics for Discussion

Howoftendoyougivebadnewstopatientsandfamilies?

Whatisthetoughestaspectaboutgivingbadnews?

Arethereparticularpatientswhomyoufinddifficulttotell?

Can you recall a negative experience that you had with breaking badnewsfromearlyinyourcareer?Aretheretechniquesthatyounowusethatwouldhavemadethatexperiencegobetter?

Can you recall a recent clinical experience that you feel went as wellasitcould?Whattechniquesareyounowaccomplishedatusing?

Have you developed a particular strategy, plan, or method for givingbadnews?

Whatwouldyousayyourstyleis?Areyoulikelytobeblunt?Doyoutailoryourdeliverytothepatient?

Have there been times when the news was so difficult to give thatyou“candy-coated”theinformation?Orleftoutsomeofit?

Whatfeaturesoftheintervieworpatient’sreactiondoyouregardasindicatingthatyoudidagoodjob?Doyouuse techniquesthatregularlyproducethesereactions?

Do you particularly dread the patient becoming very angry, crying,orbecomingverydistressed?Isitadilemmaforyouwhenapatientsays“Idon’twanttoknow”?

How do you combine fostering hope with delivering unfavorable medicalinformation?

Howdoyouaddressfamilies’requeststowithholdbadnewsfromthepatient?Doyoufindthatfamilyconferenceshelp?

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NOTES

“…most people who are angry are really scared”

“…what they want more than anything in the world is you, your good graces… they need you”


THE ANGrY PATIENTAmong the many possible reactions to bad news, anger in a patient or relative is usually one that oncologists dread most.

Feelingsofangeroccurfrequentlyinsituationsofstress,for example, when patients are frustrated about a lab result not being ready. Anger is often a surrogate for feelings of frustration, disappointment, loss of control, demoralization, and especially fear. Many people under stress do not recognize these feelings and tend to blame others for their problems or fly off the handle. Others have learned to deal with these feelings by habitually blaming, accusing, threatening, or criticizing others. In oncology, where stress is often high, anger is not uncommon, and however many times we encounter an angry patient or relative, the experience is always uncomfortable. Anger and other strong emotions can impact the caregiver by making him defensive, causing him to withdraw or eliciting anger.

Dealingwithemotions,includinganger,requiresresponsesthatare to some extent objective—saying what you see rather than what you (at that moment) feel. Of course, dealing with feelings is perhaps one of the most psychologically demanding (and often draining) parts of doctor-patient communication often even more so when there are high hopes or expectations about theoutcome,whethertheyarethepatient’shopesoryourown,or both.

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What’s behind the anger? The wrong moment

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THE ANGrY PATIENTTopics for Discussion

How often do you encounter angry patients and familymembers?Haveyoueverbeenphysicallythreatened?

Howdoyoureacttoangerinyourpatients?Doesangermakeyougoonthedefensive,theoffensive?

Do you find it easy to identify other emotions behind patient anger?Howdifficultwoulditbeforyoutoexplorebeyondtheangertoidentifyunderlyingemotions?

Canyouidentifythesignalsofangerinyourself?Aretherereliable physical signs that you can identify as advancedwarnings?Arethereanytechniquesthatyouareawareofthatmay reduce the imminent anger (for example, are you able to use an empathic response to your own feelings, such as, “Thisismakingmeveryangry”)?

Ispatientangereverjustified?Shouldweeverapologizetopatients(forexample,aftertheevent)?

Is it appropriate to set boundaries with patients and tell them thattheirangerisintimidatingorunacceptable?

Whataboutpatientswhoareoutofcontrol?

Are any of your colleagues particularly capable of dealing with patients’anger?Whathaveyouseenthemdo?

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NOTES

“…not robbing people of hope without giving false promises”

“… what you’re telling me cannot be—we thought we brought him to the best hospital in the world”


HOPE & EXPECTATIONSDealing with another person’s emotions is always difficult, but it is even more difficult when there are high hopes or expectations—whether the patient’s or the physician’s.

Manycliniciansidentifythetaskofkeepingapatient’shopealive or its complement, tailoring communication so as not to “destroy hope,” as one of the most important challenges in communicating with patients. Keeping hope alive while being honestwithpatientsisafrequentdilemmafacedbyphysicians.

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Unrealistic hopes False hopeDespair

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HOPE & EXPECTATIONSTopics for Discussion

Whatisyourpersonalunderstandingofhope?

Whatisthephysician’sobligationregardingpatients’hopes?Howcanyoudeterminewhatpatients’hopesare?Howwouldyouask?

Isthereanobligationnotto“destroyhope?”Howdoyouhan-dle the issue of hope in a newly diagnosed patient with a poor prognosis?

Have you found yourself in situations where there was a serious disconnection between you and the patient regarding theirunderstandingofthemedicalfacts?

Do you feel that patients tend to distort information in order to “maintaintheirhope?”Areyoueversurprisedatwhatpatientscome up with when you check their understanding of the medicalfacts?

Whatdoyouthinkhopeisforthepatient?Isitalwaysacure?Arethereothertypesofthingstohopefor?Doyouviewyourpatients’hopesassingularandfixated,perhapsfocusedoncure,ormultifacetedandmultifactorial?Doyouusetechniquesthatcanidentifytheelementsofyourpatients’hopes?

Whatdoyoudowhenapatient’shopesareunrealistic?Howcan you introduce reality without seeming cruel or apparently abandoningorcrushingthepatient?

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NOTES

“Should I never be friends with a patient?”

“The thirty year old who just got married and is going to lose his rectum and may be dead in five years… it’s not easy to tell someone that”


SYMPATHY, EMPATHY & PErSONAL BOuNdArIESYour own personal boundaries, including the line between sympathy and empathy, are always a challenging part ofyour job.

Dealing with our own hopes and emotions raises the central issue of boundaries and the nature of the relationship between the professional and the patient. In the next section, we discuss the difficulty in drawing our own personal line between our professional functions and ourselves as fellow humans or even friends.

Acknowledgingandrespondingempathicallytothepatient’semotionsmaybequitedifferentfromthefeelingyouyourselfhaveaboutasituation.It’shelpfultobeawareofthedifferences. An important dictum of medical ethics warns the doctor not to get too close to his or her patients for fear of disturbing the objectivity needed to provide care. However, doctors do have feelings for their patients, and these may intensify in situations where care is given over a long period of time. Some patients more than others touch us emotionally, and sometimes physicians become close friends with their patients. This may be one reward of medicine, but the situations dramatized in the video illustrate the importance of giving some thought to your feelings for your patients.

Howevercarefullyonetriestodefineone’spersonalboundaries,in many respects, achieving a rapport with a patient may result in the physician feeling a sense of loss later on. In fact, it is likely that the sense of loss cannot be eliminated in many clinical situations, particularly in oncology.

Sympathy EmpathyAttachments Friendships27

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SYMPATHY, EMPATHY & PErSONAL BOuNdArIESTopics for Discussion

Doyoufindyourselflikingsomepatientsmorethanothers?

Do you create “internal barriers” to protect yourself from getting tooemotionallyinvolvedwithpatients?Howdoyoudothat?

Can you readily identify those of your patients who have become friends?Howdoyouevaluatethepotentialrisksofthat?

Haveyoueverbecomeclosefriendswithapatient?Gonetopartiesattheirhouse?Acceptedgiftsfromthem?Arethereanyriskstothiskindoffriendship?Whatarethey?Shouldphysicians accept trips or vacations to visit patients who, for example,liveabroad?

Do you feel that when patients become friends, it can compromiseyourjudgmentabouttheircare?Whatdoyouthinkthepatientfeels?

Doyouevergivepatientsahugorkiss?Doesitmakeyoufeeluncomfortablewhenpatientswanttoembrace?Wheredoyoudrawtheprofessionalboundaryintheseinstances?

What are the factors that make giving bad news to a patient whohasbecomeyourfriendeasierormoredifficult?

Do you think that physicians can learn to be both emotionally attachedtopatientsandobjectiveabouttheirmedicalcare?Doyouthinktheyshould?

Have you ever found yourself offering unnecessary treatment to apatientbecauseyoufeltpainedattheirplight?

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NOTES

“I don’t think you can train for this until you’ve been through it”

“I felt terrible. And he said, ‘yeah, but you gave me four and a half years’ ”

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THE dYING PATIENT & THE PHYSICIANCare of the dying often reflects the underlying physician-patient relationship and can strain it or sometimes strengthen it.

Loss is inherent in the care of the cancer patient, since only 50% of patients on average live for more than five years. Thus, the care of the dying is as important as the care of those doing well. Losing patients is never easy, and this is made more difficult when we have become close to them, when they are youngandhavenotfulfilledlife’sdreams,orwhentheir courage and perseverance have touched us in some way. Yet, in medicine, death is often seen as the enemy, and training does little to prepare one for the sense of defeat that can occur when patients die, despite our best efforts.

Even recognizing the death of a patient as inevitable may not remove the emotional impact on the physician. When you experience strong emotions—and we all do from time to time— it’simportantthatyouacknowledgetheirexistence.

Distancing Continual loss A good death

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THE dYING PATIENT & THE PHYSICIANTopics for Discussion

How much training have you had in the topic of death and dying?Cantraininghelpyouprepareforhandlingpatientloss?

Whataboutyourownfeelingsofgrief?Howdoyouhandlethedeathofpatients?Doyoueverwritetofamilies?Attendfunerals?

Doyouuseanyparticulartechniquestodealwiththedeathofapatient?

Have there been occasions when you have contemplated your ownmortalityanddeath?Didyoufindyourselfmakingplansfordealingwithit?Didtheplanningexacerbateoramelioratetheintensityofyourownemotions?

What would you want from your physician in dealing with yourowndying?Howcouldheorshehelpyou?Whatwouldyouwantthemtoofferyouintermsofinformation?Decisionmaking?Emotionalsupport?

Do you ever find yourself doubting or second-guessing your medicalcarewhenyourpatientsdie?

Can you recall patients whose deaths have caused you particular emotionalpain?

Doyousometimesfeelburnedoutbythedeathsofyourpatients?Whatisthatlike?

Doyouthinkthatthereare“gooddeaths?”Whataboutpatientswhoarenotpreparedfordying?

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NOTES

“You have to have some way to deal with that, some outside interest, some kind of belief system that helps you deal with it”

“…when we go on vacation, the beeper does not go with us”

“…it’s one or two days before you realize that the rest of the world doesn’t always think about cancer”


HOW TO COPECoping strategies are mechanisms that help reduce the sense of stress and emotional load; they can be practical, psychological, or both.

A recent study showed that over 60% of oncologists feel burned out. That is, they feel demoralized and often depressed about their profession. There are many causes of burnout—the long hours, bureaucratic hassles, the toll of taking care of so many very ill patients, the demands of families and their own feelings of helplessness at watching people die as well as the pain of families. Yet, somehow we must cope with the everyday care of patients and get up the next day and do it again. The video excerpts in this section illustrate some ways that cancer doctors get through all of this.

Perhaps the concept of the “renewable resource” is a useful analogy here. If you are able, through various coping mechanisms and strategies, to replace the psychological energy and reserves that are lost in daily clinical practice, you will manage to maintainsomeformofequilibrium.Ifyoucannotdothat—and we all have days when we cannot—then that may produce burnout in the long term. Reflecting on and discussing this topic may be as important—perhaps even more important—than any of the other topics, because if you are burnt out, you will be unable to help your patients deal with their own burdens.

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Off service Creating “safe” space Setting boundaries

36


HOW TO COPETopics for Discussion

Howdoesthedailystressofclinicalcancercareaffectyou?Canyouidentifythefeaturesthatmakeadayreallytough?

What helps you cope with the stress of everyday oncology practice?Whatrestoresyourownsenseofenergyandenthusiasmforyourjob?Doyouworkout?Haveahobby?

When your patients thank you, are clearly glad to see you, or are gratefulforyourhelp,doesthatreducethestressesthatyoufeel?Can you easily acknowledge the gratitude of patients and family members?

Are there things that you wish you could avail yourself of to get throughthelossesandstresses?

Isfamilysupportanimportantfactor?Whathaveyounoticedaboutthis?

Doyoueverfindyourself“dumping”yourstressonyourfamily?Do you ever find yourself relying on self-destructive coping such asexcessivealcoholuse?

Howdoyougiveyourselfabreak?Bytakingvacations?Planningregularculturalorotherevents?Doesyourhospitaloroffice have a place such as a lounge or office where you can take abreak?

Doyoufeelthatyourhomeandworklifeareinbalance?

Doyouhaveanycolleaguestotalktoabouthowyoufeel?

Doyouknowmanycolleagueswhoseemstressedandburntout?

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NOTES

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IN CONCLuSIONEveryone who has been involved in this project hopes that the videotape and this booklet will help crystallize some of thebiggest problem areas in cancer care and that they will provide some strategies for dealing with them effectively. Nobody who goes into the practice of oncology expects it to be easy. But, asthe scenarios show, sometimes the practice of oncology is more difficult than anyone could imagine. If this tape and booklet lessen that difficulty and in the process help you become abetter caregiver to your patients with cancer, then this project will have fulfilled its aim.

Appendix I

S-P-I-k-E-S COMMuNICATON PrOTOCOLS-P-I-K-E-S is a communications protocol for difficult clinical situations,suchaswhenit’snecessarytoimpartbadnews.Itissummarized briefly below. You will find more detail about this protocol and how to use it in the Annotated Bibliography that follows.

Setting Before you begin, attend to the context in which the conversation will take place. This includes such things as choosing a private setting rather than a public hallway,determiningwhois(andisn’t)present,sittingratherthanstanding.

PercePtionTake time before beginning to determine what the person knows or suspects about the medical situation. “Tell me what you know so far about your condition…” Note any mismatch between this and the actual medical information.

invitationEncourage the patient to let you know how much detail he/she desires. “Are you thesortofpersonwho…”Acceptthepatient’srightNOTtoknow(butoffertoanswerquestionslatershouldtheyarise).

KnowledgeBegin to impart information (in small chunks), checking reception as you go, and respondingtopatient’sreactionsastheyoccur.

ExPloration Explorethepatient’sunderstandingofwhat’sbeensaid,andrespondtoemotions.“Icanseethiswasmoreseriousthanyoususpected…”Thisdoesnotrequireyou to experience the same feelings as the patient or to agree with his/her view or assessment.

Strategy & SummaryPropose the best medical strategy, assess patient response, and agree on a plan. End the session by summarizing, and then ask whether there are important issuesorquestionstodiscuss.Offerassurancesthatyouwillanswerquestionsthat arise later. Make a clear contract for the next contact.

Notice that the protocol calls for easing both the patient and the physician into the situation by first attending to the context of the conversation, by gathering information before imparting it, by giving feedback and acknowledgment, and by providing the structure of a summary.

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Annotated Bibliography

TIME PrESSurESBaker Laurence H, O’Connell, D and Platt, FW “What Else?” Setting the Agenda for the Clinical Interview. Ann Internal Medicine 2005;143(10), 766-770.

Many times patients have concerns that go unexpressed until the end of the interview when the clinician thought that he had covered the important points of the encounter. This paper is a useful article on how elicitingthepatient’sagendaatthebeginningoftheinterviewcansavetime later on.

Beckman H, Markakis K, Suchman A, Frankel R. Getting the most out of a 20-minute visit. Am J Gastroenterol 1994;89:662–4.

A discussion of four core skills that can increase the efficiency of the medical encounter and enhance the feeling of co-participation in problem-solving by the physician and patient.

Dugdale, DC Epstein R. and Pantilat, SZ Time and the Patient–Physician Relationship. J Gen Intern Med. 1999 January; 14(S1): S34–S40.

An overview of the issue of time pressures in the physician-patient encounter and some suggestions as how to use interview skills to save time and improve important outcomes of patient care.

Gunderson L. Physician burnout. Ann Intern Med 2001;135:145–8.

A brief overview of the concept of burnout and approaches for physicians to combat it, including the American College of Physicians–American Society of Internal Medicine Renewal Project.

Lang F, Marvel K, Sanders D, Waxman D, Beine KL, Pfaffly C, McCord E. Am Fam Physician. 2002 Apr 1;65(7):1277-9.

Interviewing when family members are present. In oncology family members often accompany patients to interviews. This can create challenges but also opportunities to involve them in the support of the patient. This article briefly discusses a core set of interviewing skills for involvingfamiliesinthepatient’scareandmoreadvancedskillsfor managing conflict and negotiating goals of care.

Lee Rs, McGrath P . Dealing with Time Pressure. International J Stress Management 1995;2(2) 79-86.

A study of individuals experiencing time pressure during personal encoun-ters revealed that those who felt effective in focusing on the task at hand,

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viewed the encounter with a person as a challenge rather than a burden and set realistic goals were more likely to feel less time pressure and more likely to show satisfaction with the meeting.

Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM, Leaning MS, Snashall DC, Timothy UK. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer 1995;71:1132–3.

Emotional exhaustion, depersonalization, low personal accomplishment, and psychiatric disorders among cancer clinicians were associated with feeling overloaded, treatment toxicity/errors, and deriving little satisfaction from professional status. Clinicians who felt insufficiently trained in communication and patient management skills had significantly higher levels of distress than those who felt sufficiently trained.


Baile WF, Beale E. Giving bad news to cancer patients: matching process with content. J Clin Oncol 2001;19:2575–7.

Howafailuretounderstandapatient’sexpectationsandanxietiescan lead to misunderstanding and conflict in the doctor-patient relationship. Suggestionsforwaystoefficientlyexplorepatients’expectationsand concerns.

Branch WT, Malik TK. Using ‘windows of opportunities’ in brief interviews to understand patients’ concerns. JAMA 1993;269:1667–8.

How to pick up on verbal cues from patients during appointments to identifyissuesthatareofconcerntothemandthatmayaffecttheirqualityof life, satisfaction with medical care, and compliance with treatment.

Smith RC, Hoppe RB. The patient’s story: integrating the patient- and physician-centered approaches to patient interviewing. Ann Intern Med. 1991;115: 470–7.

Techniquesforelicitingthepatient’sperceptions,needs,andconcernsinthe context of the medical interview and the advantages of this approach for patient management.

Voices From the Lived World of Illness: Advanced Cancer DVD

The film leads the viewer into the “in-illness” experience and highlights patient’sexpectationsofdoctors,theimpactonone’ssenseofselfand relationships with others, spiritual issues, dying and hope. Available at http://www.communicationinmedicine.org/

BrEAkING BAd NEWSBuckman R. How to Break Bad News. A Guide for Health Care Professionals. Baltimore: Johns Hopkins University Press, 1992.

A comprehensive guide and six-step protocol for telling families and patients about adverse medical information.

A Request for Nondisclosure: Don’t Tell Mother Hallenbeck J and Arnold R. J. Clin. Oncol. 2007; 25: 5030-5034.

What to do when family or loved ones want to withhold bad news from patients.

Guten CF, Ferris FD, Emmanuel L. Ensuring competency in end-of-life care. Communication and relational skills. JAMA 2000;284:3051–57.

An expansion of the Buckman six-step method for giving bad news that includes setting treatment goals, advance care planning, withholding or withdrawing therapy, making decisions about life-threatening illness, resolving conflict around futility, and discussing death and dying.

Lubinsky MS. Breaking bad news: dealing with the mimics of denial. Journal of Genetic Counseling 1994;3:5–12.

Differentiates “true” denial (repudiation of reality) from a number of more benign coping strategies (disbelief, deferral, and dismissal) used by patients and families when dealing with bad news.

THE ANGrY PATIENTAstrow AB. Isn’t there someone to blame? J Clin Oncology2007;26(9):1560-1561.

Discusses how the oncologist can frame and survive the anger and blame that may emerge in patients around death and dying.

McCord RS,Floyd NR,Lang f and young VK. Responding to anger directed at the physician. Fam Med 2002;34(5):331-336.

It is suggested that apologies and explanation are likely to be most effective insimplesituationssuchaspatients’beingkeptwaiting.

Platt FW, Gordon, GH. Anger. In: Field Guide to the Difficult Patient Interview. Philadelphia: Lippincott, Williams & Wilkins, 1999, pp 75-83.

How patient anger affects the physician, and some practical management tips, including pitfalls to avoid.

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HOPE & EXPECTATIONSEvans WG, Tulsky J, Back AL and Arnold RM. Communication at times of transitions: how to help patients cope with loss and re-define hope.

A review of the dynamics of patient challenges as they face losses associated with phases of their illness and several strategies that may accomplish the goal of helping them to maintain hope.

Fallowfield L. Truth sometimes hurts but deceit hurts more. Ann NY Acad Sci 1997;809:525–36.

Discusses the implication of clinicians concealing or altering medical facts to protect the patient from “losing hope.” Argues that most patients today desire accurate information across the disease spectrum and that most patients also have mechanisms to assist them in coping with bad news. Suggests that, for most patients, health care providers will accomplish much by focusing on helping patients redefine hope in terms of realistic goalsofcareandmaintainingqualityoflife.

Gerretsen P and Myers J. The physician: A secure base. J Clin Oncol 2008;26(32): 5294-5296.

A case discussion raises the point that patient comfort can be derived from the perception of physician availability that provides the security that comes with feeling one is not alone.

Sardell AN, Tierwieler SJ. Disclosing the cancer diagnosis. Procedures that influence patient hopefulness. Cancer 1993;72:3355–65.

The authors empirically examined the extent to which various forms of physician disclosure of a cancer diagnosis are seen by patients as more or less hopeful and as favorable or unfavorable.

SYMPATHY, EMPATHY & PErSONAL BOuNdArIESBanja JD. Empathy in the physician’s pain practice: benefits barriers and recommendations. Pain Medicine 2006; 7(3): 265-275.

Explores the phenomenon of empathy from the perspective of the physician and proposes a communication model valuable in communicating when facing challenging emotional situations.

Gabbard GO, Nadelson C. Professional boundaries in the physician-patient relationship. JAMA 1995;273:1445–9.

Discusses the limits and parameters of behavior that characterize the fiduciary relationship between physician and patient. These include sexual boundaries, gift-taking, personal disclosure, and physical contact with patients and families. Factors leading to boundary violations and ways to increase awareness of and to prevent them are outlined.

Meier D, Back AL, Morrison RS. The inner life of physicians and care of the ill. JAMA 2001; 286:3007–14.

Examineshowphysicians’emotionalresponsestoseriouslyillpatientscanaffectthequalityofcareandthephysician’sownsenseofwell-beingandaccomplishment. Proposes a model for increased self-awareness in identifying and working with emotions that may affect patient care.

Suchman AL, Matthews DA. What makes the doctor-patient relationship therapeutic? Exploring the connexional dimension of medical care. Ann Intern Med 1988;108:125–30.

Considers the essential elements of the relationship with a patient with a view toward defining the role of the physician in situations in which there is no appropriate biomedical response.

THE dYING PATIENT & THE PHYSICIANBaider L, Wein S. Reality and fugues in physicians facing death: confrontation, coping and adaptation at the bedside. Crit Rev Oncol Hematol 2001;40:97–103.

Describes common physician reactions to patients with cancer and how they can represent barriers to comprehensive patient care.

Berry, S.R. Just Say Die . Journal of Clinical Oncology 2008; 26(1):157-159

Discusses when and why oncologists and other physicians avoid using the term “dying” and how reintroduced into our discussion with terminally ill patients can actually improve their care.

Block SD. Psychological considerations, growth and transcendence at the end of life. The art of the possible. JAMA 2001;285:2898–2905.

Illustrates using cases how enhanced understanding of the common psychological concerns of patients with serious illnesses can improve notonlytheclinicalcareofthepatientbutalsothephysician’ssense of satisfaction and meaning in caring for the dying.

Mount B. Dealing with our losses. J Clin Oncol 1986;4:1127–34.

Discusses the impact of the stresses of oncology practice, including frequentpatientloss,thequestforcure,andprofessionalidealism,andsuggestsanumberofself-reflectivetechniquestodiagnoseandaddressprofessional stress.

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Renz M, Koeberle D, Cerney T and Strasser F. Between utter despair and essential hope. J Clin Oncol. 2009;27(1):146-149.

How a model of patient coping with severe illness called “the stages of maturation,” provides guidance for both compassionately and professionally accompanying patients at the end of life.

Shanafelt T, Adjei, A and Frank L. When Your Favorite Patient Relapses: Physician Grief and Well-Being in the Practice of Oncology. J Clin Oncol. 2003;21(13):2616-2619.

A reflection on how grief, disappointment and watching the suffering of others are part of caring for critically ill patients and how the importance of self-care and support are necessary in enabling us to be effective clinicians.

HOW TO COPECreagan ET Bombarded by stress. Healthy habits to avert burnout. Minn Med 1999;82: 14–5.

A practicing oncologist offers practical recommendations for dealing with the demands of clinical care.

Gabbard GO. The role of compulsiveness in the normal physician. JAMA 1985;254:2926–9.

A thought-provoking article discussing intrinsic factors in those deciding on a medical career that may predispose them to burnout, including difficulty in relaxing, reluctance to take vacations, chronic feelings of not doing enough, and other factors that interfere with the healthy pursuit of pleasure and sense of accomplishment.

Rabow MW, McPhee SJ. Doctoring to heal. Fostering well-being among physicians through personal reflection. West J Med 2001;174:66–9.

Describes a staff and faculty development program implemented at the University of California, San Francisco based on a monthly discussion group of topics meant to address existential and spiritual themes in the work of the physician. Discusses ground rules, topics considered, and feedback from physicians participating in the experience.

Shanafelt T, Chung H, White H, Lyckholm LJ. Shaping your career to maximize personal satisfaction in the practice of oncology. J Clin Oncol. 2006 Aug 20;24(24):4020-6.

How oncologists can avoid burnout and increase the likelihood of achieving personal and professional satisfaction by optimizing career fit, identifying and managing stressors specific to practice type, and achieving the optimal personal work-life balance.

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Weiner E, Swain, GR, Wolf B, Gottlieb M. A qualitative study of phy-sicians’ own wellness promotion practices. West J Med 2001;174:19–23.

Assessed the specific practices used by 130 physicians to promote wellness. These sorted themselves into five main categories. The ability to balance severalofthesetechniquesindealingwithlife’sstressorsappearedtocor-relate with improved levels of psychological functioning.

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Continuing MediCal eduCationOn Being an OncOlOgist

2nd Edition

The content of this educational activity is reviewed annually. After May, 2011, please call the Department of CME/Conference Management, at The University of Texas MD Anderson Cancer Center (713-792-5357) for verification of the sta-tus of continuing medical education credit.

To obtain credit, you must complete and submit the post test answer sheet and evaluation and obtain a score of at least 70%.

Target Audience, Purpose, Educational ObjectivesThe primary intended audience for this Continuing Medical Education material is physicians who work with cancer patients, however other healthcare professionals caring for patients should also find this program relevant to them and their clinical practices. The program was designed to “give a voice” to the often unspoken, unexplored issues and concerns that arise out of the practice of oncology, perhaps impacting the personal life and well-being of the oncologist. Its purpose is to increase awareness and promote discussion of such issues. Use of the materials as suggested will enable the practitioner to recognize some of the stressors inherent incancercareandtheirpotentialconsequencesandidentifystrategiesthatmaybehelpful in alleviating stress and enhancing relationships with patients.

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CME rEGISTrATION ANd ANSWEr SHEET

The University of Texas MD Anderson Cancer CenterOn Being An Oncologist

PROGRAM CODE: 1107

INSTRUCTIONS for AMA PRA Category 1 Creditstm

Special Prerequisites For Participants: None

To participate in this continuing medical education activity:• Viewthevideoatwww.mdanderson.org/icare,clickonEarnFreeCMECreditandscrollto the On Being An Oncologist Video• UsethepagesfromtheworkbookorprintthedocumentsfromtheWebsite• RecordyourresponsestothePost-test(scoringatleast70%ofquestionscorrect),and Mail or fax registration, answer sheet and evaluation pages to:

Department of CME/Conference Management, Unit 1381The University of Texas MD Anderson Cancer CenterP.O. Box 301439Houston, TX 77230-1439 Fax: (713) 794-4734

POST TEST: Circle best answer:

1. A B C D E 6. A B C D E2. A B C D E 7. A B C D E3. A B C D E 8. A B C D E4. A B C D E 9. A B C D E5. A B C D E 10. A B C D E

PERSONAL INFORMATION- Please print

Name______________________ Highest Degree (MD, PhD, etc.)______________

Specialty____________________________________________________________

Institution___________________________________________________________

Mailing address_______________________________________________________

City, State, Zip _______________________________________________________

Phone ______________________________Email ___________________________

TheUniversityofTexasMDAndersonemployee?YesorNoIf so, include employee ID#_________

I am claiming ______ AMA PRA Category 1 Credits™ for this activity, all of which areethics/professional responsibility credits (Maximum 3.00)

Signature______________________________________________________

NOTE: To receive credit, you must return this form and the Evaluation Form found on pages 53-55.

*

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CME POST-TEST QuESTIONS

The University of Texas MD Anderson Cancer CenterOn Being An Oncologist

PROGRAM CODE: 1107

1. Which of the following factors is mentioned in this program as a stressor specific to the practice of oncology?

A. The psychological burdens that patients bring to the situation related to their diagnosisB. The ever-present threat of death and dyingC. The effect of lack of sleep on the doctorD. The pressures of managing timeE All except C

2. According to this program, which of the following are potential negative effects on patient care of ignoring such stressors?

A. Unrealistic hopesB. DemoralizationC. Emotional withdrawal from patients, resulting in cold or detached delivery of careD. Inability to discuss end-of-life issues with patients and familiesE. All of the above are mentioned

3. What are some of the strategies for offsetting such stressors that are specifically mentioned in this program?

A. Talking with colleagues, role models or mentorsB. ShoppingC. Taking time offD. Acknowledging and discussing stressorsE. All except B

4. In the section on Time Pressures the discussion is about all of the following except:A. Not seeing the patient for a period of time that seems long enoughB. Being constantly behind at workC. Missing events with family because of work D. How to manage your time appropriately

5. Which of the following items are discussed in the section on “Breaking Bad News?” A. Differences in giving bad news to a patient you have known for a long time and having to give bad news to someone you have just metB. Suffering is not just physical pain, but a threat to the integrity of the human being C. Obligations and truth tellingD. All of the above

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6. When discussing angry patients, Megan Cole states that she came to realize that:A. It is always best to call a patient advocate when the patient is angry B. Most people who are angry are really scaredC. It is a really good idea to call in the legal department right from the startD. All of the above

7. Which of the following describes how William Hurt stated he dealt with angry patients?

A. He leaves the room and counts to 10 slowly before beginning the discussion B He asks the patient to take a deep breath and count to 10 before beginning the discussionC. He acknowledges that the anger is appropriate, but not helpfulD All of the above

8. In the section on Sympathy, Empathy and Personal Boundaries which of the following is not discussed?

A. Demands of being a caregiver at home and at workB. Emotional involvement with patientsC. How to break bad news to the family in a compassionate mannerD Studies stating that Medical Students interact better with patients, interns worse, residents worse and fellows worst of all.

9. In the section on the Dying Patient & The Physician, Megan Cole describes all of the following except

A. The reality that patients die creates emotional tension that is always thereB. The concept of a good deathC. Agitated family members who want a lung transplant for the patientD. How to resolve conflict with the patient and family members

10. In the section of “How to Cope” which of the following suggestions are mentioned?A. The need for a lounge and exercise roomB. Realizing that if you are struggling hard, it is because it is hardC. No pager when on vacation and having someone who tells youtheyknowit’shardD. All of the above

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CME EVALuATION

NOTE: For credit you must fax both sides of this document and return with the registration/answer sheet form. Test questions do not need to be faxed.

Program Name: On Being An OncologistDate: ____________________________Program Code: 1107

1. I am a: Physician Non physician, please specify _________________________________________________

2. The program content helped me achieve the following objectives categorized as knowledge (principles learned), competence (ability to apply knowledge), and/or performance (skills, abilities and strategies implemented in practice) and/or patient outcomes (changes/improvements in patient care/patient health status).

StronglyAgree

AgreeUnde-cided

DisagreeStrongly Disagree

Objective A: Identify daily dilemmas and stressors involved in oncology clinical practice that may negatively effect doctor/patient communication (knowledge)

Objective B - More openly discuss feelings offrustration,inadequacyandburnoutwithout feeling ashamed, thereby mak-ing these feelings/stressors less noxious (knowledge)

Objective C - Develop new and different coping strategies, new insights and new per-sonal resources (knowledge and competence)

Objective D – Distinguish that these feelings/emotions are normal and, through acceptance of this, be able to move from the realm of being stressful to the promotion of professional growth (knowledge, competence)

3. 0-25% 26-50% 51-75% 76-100%

Whatpercentageoftheobjectivesweremet?

What percentage of this information was newtoyou?

4.Knowledge Competence Performance

PatientOutcomes

Overall the information presented willenhance my practice in the following manner.

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5. As a result of your participation in this activity, what will you do differently than you did beforeinyourpractice/researchactivities?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6.Whatarethebarriersorotherfactorsthatmaypreventyoufromimplementingachangeinpractice?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7.Howwilltheinformationpresentedimpactpatienthealthstatusinyourpractices?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8.Whatquestionsdoyouhavethatyouarenotgettinganswerstoand/orwhatpatientproblemsorpatientchallengesdoyoufeelyouarenotabletoaddressappropriatelyortoyoursatisfaction?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

9.Strongly

AgreeAgree Undecided Disagree

Strongly Disagree

In general, the overall organizationandqualityof the program met my expectations

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

10. Was any bias toward a commercial interest* noted in the information provided (products/ servicesundulyfavoredorpromoted)?

*A commercial interest is any entity producing, marketing, re-selling, distributing healthcare goods or services consumed by, or used on patients. The ACCME does not consider providers of clinical service directly to patients to be a commercial interest.

YES NO

If yes, please identify product/service, faculty, and/or presentation(s) ______________________________________________________________________________________________________________________________________________________________________________

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11.Whatchangeswouldyourecommendtomakethisactivityamoremeaningfulexperience?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

12.Whattopicswouldyousuggestforfuturepresentations?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Documents

On Being An Oncologist