Professional burnout syndrome is increasing among doctors working in palliative care, and several studies have attempted to investigate whether this common problem has a higher prevalence among palliative care specialists. However, the answer may lie not in figures or specialties, but in the working conditions of health professionals and in their approach to life.

Eduardo Bruera, MD, is an Argentine oncologist and founder and chair of the Department of Palliative, Rehabilitation and Integrative Medicine of the University of Texas MD Anderson Cancer Center in Houston. He has been a driving force in palliative care for 15 years. He told Medscape Spanish Edition that the rate of professional burnout in this specialty has been increasing, and that it results from a combination of issues related to patients, professional training, and working conditions.

Suffering Patients

“We are obviously exposed to suffering, and it would be simplistic to think that we can sweep that away when we leave the hospital,” said Bruera, noting that the condition is more marked in this specialty because of its focus on the patient as a person. “Where an oncologist sees a patient as a stage IV carcinoma that has not responded to chemotherapy, the palliative care specialist sees him as a 45-year-old architect and a father of two daughters, with a good relationship with his wife and a conflicting relationship with the fact that his life is coming to an end. All those aspects of people that other doctors don’t look at make us more likely to suffer from identification, by empathizing with what’s happening to the patient.”

A career in palliative care exposes specialists to patients who are suffering physically, emotionally, and spiritually. “The end of a life will always be very sad, and it’s important to recognize that. But if our aim is to eliminate that suffering, we’ll burn ourselves out, because we’ll end up feeling extremely incompetent and powerless. We need to understand that there’s a limit to what we can do with our limited resources.”

Know Your Limits

Medscape Spanish Edition also spoke to Enric Benito Oliver, MD, PhD, co-director of the expert course on Spiritual Guidance in the Clinic at Francisco de Vitoria University in Madrid, Spain, and honorary member of the Spanish Society for Palliative Care, who developed a severe case of professional burnout syndrome after 20 years in clinical oncology. This burnout transformed him, and he switched to working in palliative care, where he was exposed to “the suffering of patients and their families.”

“Dying is not a disease,” said Benito Oliver. “Keeping someone alive for an unreasonable length of time is inhumane, toxic, and very expensive. It increases suffering and it leads to professional burnout.” To prevent this, he agrees with Bruera that professionals need to know their limits.

He also said that palliative care specialists are a special case. “We are lucky not to have to treat anyone, which is a great advantage, because we want to work with people, not diseases. I can’t hide behind an MRI, a lab test, or a promising treatment. All I can do is keep close to the person who is going to die and stay with them throughout that process. As well as the obvious scientific skills needed to control their symptoms, I also need a sophisticated understanding of emotions. That makes us experts in the inner worlds of patients and professionals.”

Benito Oliver noted that professionals can suffer for many reasons, but the main reason is depersonalization. “A doctor who is working under great emotional strain, surrounded by suffering, but lacks the tools to understand and manage their own emotions will depersonalize to avoid becoming too involved with the patient’s suffering. That sets them on the path to self-isolation.” This situation can lead the professional to become too emotionally involved and develop empathetic burnout, secondary traumatic stress, or professional burnout syndrome.

Lack of Training

Younger people are at greater risk of experiencing professional burnout. According to the two specialists, a lack of proper training greatly increases the chances of developing this syndrome.

Benito Oliver suggested that what distinguishes those who are better at coping with burnout is their inner world: their ability to connect with themselves, set limits, and enjoy their work. He maintained that effective emotional regulation is essential for doctors who are exposed to the suffering of others. It reduces counterproductive feelings of fear and alarm and frees up their processing capacity to help others.

Benito Oliver runs courses that teach methods for developing these abilities and offer practical tools for understanding and managing suffering in the clinic, acknowledging the difficulties for professionals.

Professional Difficulties

Self-care should not be left until after work but should be performed as part of the working day, in part by setting limits on situations that cannot be changed, said Benito Oliver. But this is not the only factor.

An exclusive focus on palliative care and the type of palliative care unit were associated with lower levels of fatigue. Professionals who provide palliative care in general settings experience more symptoms of professional burnout syndrome than those in specialized palliative care settings.

These issues are common in Latin America where, according to Bruera, professionals are of excellent quality but work under very difficult conditions, often without proper acknowledgment. “There has been a lot of progress in Argentina, as well as in Chile and Brazil, although less systematically. Colombia has done very well in several regions, but in Mexico, while there are excellent groups in some areas, progress has been limited and erratic.” In addition, there is a lack of recognition of this specialty within medical faculties, as well as by hospitals and insurers.

Bruera explained that the increased risk for burnout in recent years can also be explained by changes in the profession. In the past, patients came to palliative care very close to the end of their lives, in a protected and controlled environment (hospitalization or palliative care units) with access to multidisciplinary groups, when other specialists had already pulled back. “By moving us earlier in the course of the disease, we see the patient much more often, under working conditions where we have no team and no control over what happens to the patient, because their treatment is ‘owned’ by the oncologist, the cardiologist, the pulmonologist, or the neurologist. So, our relationship is more complicated.”

Bruera noted that the increase in professional burnout is primarily related to worsening working conditions, and that changes in these working conditions will also provide the solution. He has no doubts about that. “To reduce professional burnout, you need a good working environment and a good boss. The two main causes of the problem are your direct manager and your employer.”

“If people are overloaded with work, it’s not enough to ask them to meditate or exercise and to quantify their burnout, because that’s not a good way to measure the outcomes of those interventions. If my working conditions are miserable and my boss is a tyrant, meditating, watching what I eat, or doing a little exercise won’t get rid of my burnout — that’s too simplistic.”

Improving Working Conditions

Bruera helped draft the recommendations from the American Society of Clinical Oncology, which state that the oncology community has an ethical imperative to develop and support organizational, individual, and systematic interventions to directly address professional burnout within oncology, because the risk factors also include occupational factors (such as high patient loads, greater administrative responsibilities, use of electronic health records, etc.).

“The most important thing about that document,” Bruera said, “is that it opened the door to understanding that this is a serious problem linked to working conditions, which is something we doctors had not registered and is often a taboo subject.”

Bruera said that it’s common for affected professionals to think that they are weak or that burnout is a personal problem rather than a collective issue. “This document legitimizes the fact that some of us are suffering, that working conditions have changed, and that medical practice, oncology, and palliative care involve more suffering than they did 15, 20, or 30 years ago. It shows that we are justified in feeling like that. That legitimization has put the ball in the right court: in the court of the hospital directors, the bosses, the decision-makers. The issue can’t be ignored anymore. This is the first step toward improving our working and living conditions.”

“Until now, very few centers have started to realize that we are people who look after people, not bodies and brains who look after diseases,” said Benito Oliver.

Practicing Self-Care

When doctors try to “endure” or ignore stress, the symptoms of professional burnout syndrome become chronic. This development is associated with physical health conditions (cardiovascular disease, chronic fatigue, cognitive dysfunction, insomnia, gastrointestinal problems), mental health problems (depression, anxiety, substance dependency, suicide), and disruptions to their personal lives. Its harmful effects on problem-solving and decision-making can also put the patients they care for at risk.

Bruera’s book, Some Notes for Physicians Contemplating a Career in Palliative and Person-Centered Care, also has an entire chapter focusing on self-care.

“There is evidence that all of these techniques — meditation, physical exercise, a good diet, and using other parts of the brain such as spirituality or creating art instead of watching trash TV — are useful for managing stress, anxiety, and depression, based on a certain level of evidence at the individual level for small improvements in professional quality of life and other mental health issues,” he said.

The text provides a set of guidelines for weekly self-care and another for daily self-care. “Several members of our team use most of these measures on a regular basis,” said Bruera.

Benito Oliver suggested similar strategies for promoting or maintaining physical, mental, emotional, and spiritual health, emphasizing that self-care requires self-reflection and self-awareness to identify the relevant stressors and supports in both personal and professional settings. He spoke about the importance of social self-care and the support network consisting of family and friends, “a community where you can find some balance.”

“The best thing we can do if we see that one of our colleagues is going through this is to take them out for a coffee. Sometimes we need someone to sit down with us and talk about forms of self-care, and to suggest seeking professional help,” he added.

Spiritual self-care refers to a deeper dimension of being human. “I’m not just talking about mindfulness, prayer, or yoga, but all of it: any spiritual practice that the professional carries out and that gives them a consistent way to stay calm, present, and balanced in the face of conflict in care,” said Benito Oliver.

Much research on the effectiveness of individual interventions aimed at reducing professional burnout among physicians suggests that people may receive similar benefits from various approaches, and that using these interventions simultaneously can increase their efficacy. However, a meta-analysis shows that the results are limited and inconsistent and that further research is needed in oncological settings.

The potential utility of mindfulness-based interventions has been investigated for healthcare workers, but a systematic review of the literature found no high-quality evidence. Interventions based on meditation, improving communication skills, peer coaching, and art therapy–based supervision had positive effects, but the long-term outcomes are still unknown.

In summary, there is insufficient empirical clinical data to support this theoretical model of self-care, but there is a consensus that it should be used and its impact should be assessed. Movements in this direction, to improve the well-being of health workers, are growing more and more common. Institutions are implementing wellness infrastructures and activities to reduce professional burnout.

Bruera and Benito Oliver declare no relevant financial relationships.

Follow Roxana Tabakman of Medscape Spanish Edition on Twitter @RoxanaTabakman

This article was translated from the Medscape Spanish Edition.

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