This article appeared on OBR Oncology on January 10, 2024.
Part one of a two-part series.
Everything came to a head when JT lost a patient.
A medical oncologist in the Northeast who asked not to be identified, JT had been taking care of the woman for years. When her breast cancer turned metastatic, there was nothing else JT could do. “All the uncertainties of being a physician came to light, the uncertainties of whether or not I was doing a good job as a doctor,” said JT, who is a partner at a community oncology practice.
The patient was a mother with young children at home who depended on her. JT is a mother herself. At that time, in 2020, her youngest was a newborn. Her oldest, who has special needs, was entering adolescence. “I thought, ‘She won’t be able to watch her children grow up’ and then, ‘Oh God, what if something happens to me? As it is, I don’t get home till 8:00.’”
“All of my professional anxieties bridged with my personal anxieties.” JT found herself in a mental health crisis. The storm had been brewing. When her patient died, “It all spiraled and hit me pretty hard. Just everything was difficult.”
She’s not alone.
The pandemic was a flashpoint that expanded attention to mental health concerns among doctors. But even before COVID, such issues had been a concern for oncology professionals in particular. Oncologists see some of the sickest patients. Many of whom die. Recent, high-profile tragedies, like one involving a Mount Sinai Hospital oncologist, may not suggest a new problem for the specialty but may suggest a deepening one.
Are things getting worse? And if so, are oncologists at greater risk than other physicians?
How COVID Made Things Worse…and Better?
Quantifying mental health concerns among oncologists can be challenging, given perceived shame around physicians reporting such problems.
“There is a pervasive stigma around mental health problems in the medical profession,” says Kelly Irwin, MD, a psychiatrist at the Massachusetts General Hospital Cancer Center. “[Some individuals think] ‘I don’t want anyone to know about this.’ That’s what they are navigating.”
Dr. Irwin is president-elect of the American Psychosocial Oncology Society (APOS). The group recently co-signed an urgent call for sweeping improvements in mental health support, along with the Association of Community Cancer Centers and the Association of Oncology Social Work.
“The pandemic has raised mental health awareness in many ways. People recognize, for one, how hard it is to find mental health care for their families, for themselves,” Dr. Irwin said. But, she added, “An increased risk of suicide among physicians and oncologists [relative to the general population] is not a new problem. It’s been a significant public health problem for a long time. We know that presently 400 physicians die by suicide every year.”
COVID was a thunderclap in a storm that had long been raging, but it may also have helped push mental health issues to the fore. “Some things may have surfaced and come into the light in the pandemic and also probably worsened because of just all the multiple factors,” says Sarah Conning, LCSW, a California-based oncology social worker and immediate past president of the Association of Oncology Social Work.
A recent study shows that burnout among oncologists started increasing at a faster rate during the pandemic – from 38% to 49% over a three-month period – than it had before. Researchers cited changes at work, including less face-to-face time with patients and canceled procedures, compounded by the changes that most everyone faced as part of the reason oncologists’ mental health took a hit during the pandemic.
Things certainly didn’t get better for depression and anxiety among oncologists, but it may have become more okay to publicly not be okay. “It was normalized. Help was available. It was easy and rapid, and there was a recognition that this is hard for us all,” Dr. Irwin said.
However, the pandemic also added fuel to the fire in a specialty that often disproportionately confronts patient death. “Many people delayed cancer screenings during the pandemic, so oncologists began seeing an increase in cancers that weren’t caught earlier,” Conning explained.
Nationwide, early-stage cancer diagnoses were down 20% in 2020, according to a study published in The Lancet. A report from the UC Davis Comprehensive Cancer Center found that, in the state of California, 17 of 21 common cancers were diagnosed at significantly lower rates in 2020 than in previous years. There were up to 50% fewer than expected early-stage diagnoses of all screening-detectable cancers in the state that year. With delayed diagnoses, potentially life-saving treatments may be delayed as well.
“That’s a pretty bitter pill for doctors who have access to incredible treatments, and they weren’t able to use them because their efforts were interrupted by a pandemic,” Conning added.
Oncology-Specific and Broad Stressors in Medicine Take Toll
COVID isn’t the only contributing concern. Experts note that oncologists often see patients suffer more during treatment than other specialists, given the toll various cancer treatments can take. The mortality rate can be high. Some within oncology describe “secondary trauma” or “compassion fatigue” associated with a burden that is excessive even when compared with other internal medicine specialties.
This is what exacerbated JT’s personal struggle. As she explained, “Despite your best efforts, things don’t always turn out well. They don’t always do well with whatever treatment you prescribed. And that can be a lot.”
There are other exacerbating issues. Researchers have highlighted the “moral injury” and “moral distress” that come from systemic barriers in cancer care that can make it difficult for physicians to do what they know is right. “There are definitely factors related to the dysfunctions and inequities in our healthcare system, where people could be helped by cancer treatment, but there are barriers that prevent them from getting it,” Conning explained.
The Culture of Medicine
One of the biggest known drivers of mental health challenges for all physicians remains the culture of medicine. “There’s very much an ethos of ‘Suck it up and get through it,’” Dr. Irwin said. “They think of mental health problems as something to get through rather than a true medical problem.”
Additionally, many doctors say they “suck it up” because an admission of mental distress could threaten their careers. In 24 states, medical license applications include questions about past mental health diagnoses and episodes, rather than strictly focusing on whether a currently untreated medical issue may impair a physician’s ability to care for patients.
But not everyone feels the same pressures. Various studies have indicated that depression, anxiety, and suicides are more commonly reported among female physicians than males. For JT, who is the only female partner in her community practice, she feels particular pressure to keep it together at work. Her colleagues don’t accept that the demands of home life can get in the way of professional life, she explained, which only leaves her feeling more pressure.
“If I say I will be a half-hour late because I need to take my child to school, one of my male colleagues will say to me, ‘You need to get a wife.’”
Even if the culture encouraged doctors to seek mental health care, the workflow does not easily allow for it. “The way training programs are structured, the way clinic schedules run, they do not facilitate or encourage seeking therapy or seeing a psychiatrist during the workday,” Dr. Irwin noted.
JT said it is all she can do to fit in her own recommended mammogram around her clinic schedule. Given these barriers – overwhelming hours, the need to keep a low profile, and demands at home – JT finally decided to talk to an online therapist. After a few sessions, she didn’t feel she was getting much of a return on the substantial investment of time and energy. So she stopped.
“What do I do now? Nothing specific,” she said. “There’s never been a resolution per se. There are times when things may bother you more. And there are times when they’re not as bad.”
“I guess things just go on.”
Looking Towards Solutions
Many advocates in the field are determined to avoid allowing these concerns to simply “just go on.”
“We need to create a culture of seeking mental health treatment and decrease barriers to seeking care,” Dr. Irwin emphasized. “Connecting people to treatment has incredible potential to relieve suffering and prevent further harm to a group of really good, thoughtful people who are doing hard work.” Some institutions are making strides in fostering a workplace culture that encourages clinicians to seek mental health care and offering the resources to back them up.
The second installment in this series explores promising solutions and strategies designed to mitigate mental health concerns faced by oncologists.
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Oncologists Need the “Source of the Bleeding” Stopped When It Comes to Mental Health
Part two of a two-part series.
Oncologists’ well-being has plummeted over the course of the past decade. A study conducted in 2023 by the American Society of Clinal Oncology found that 59% of survey respondents had one or more symptoms of burnout, up from just 34% in 2013. Part one of this two-part series explored the potential mental health epidemic occurring in oncology, as well as key underlying contributors.
Many oncologists, such as the one featured in the first part of this series, feel hopeless and alone. They feel as though the burden is on them to address the symptoms of a diseased system. “Individual support – meaning peer-to-peer counseling, psychiatric resources, resilience training – is important and necessary. It puts pressure on a bleeding wound so that the patient can survive. But it’s not enough. We also need to address the source of the bleeding,” said Stefanie Simmons, MD, chief medical officer at the Dr. Lorna Breen Heroes’ Foundation, whose mission is to reduce burnout among health care professionals.
The organization is one of several attempting to help oncologists and others in medicine by tackling the underlying, systemic issues that contribute to declining mental health. Although it is a daunting task, various initiatives to improve conditions are underway, and tangible but early progress can be seen in some areas.
Removing Barriers to Seeking Help
Although some doctors undoubtedly carry personal biases about mental illness, many legitimately fear that seeking help could cost them their careers. Until recently, most state licensing applications asked intrusive, discriminatory questions about an applicant’s mental health history. Answers to these questions determined whether the applicant could continue to work.
“These institutionalized, stigmatizing questions have been identified as one of the key barriers to health care workers receiving mental health care and one of the key drivers of health care worker suicide,” Dr. Simmons explained.
The Dr. Lorna Breen Heroes’ Foundation is working to remove these invasive questions and stigmatizing language about mental health from state licenses and hospital credentialing applications. Lorna Breen, MD, the foundation’s namesake, died by suicide in April 2020. An emergency doctor, she had been working far beyond her 12-hour shifts, treating patients with COVID-19, until she contracted the virus herself. She returned to work as soon as she was able, and was overwhelmed. She was soon hospitalized for mental health care. Shortly after her release, she died.
“Her primary concern that she had expressed to her family was that she wouldn’t be able to practice medicine again after receiving lifesaving mental health care,” Dr. Simmons said. The foundation wants to ensure that seeking mental health care never again threatens a doctor’s career.
When the organization started its initiative just a few years ago, only 17 states were aligned with their suggested criteria for destigmatization. As of Oct. 25, 2023, however, 26 state medical boards had changed the language in their applications – a shift that benefits more than 673,000 physicians. Eleven other states are in the process of making these changes, according to the organization.
Easing Administrative Burdens
Reform at the state medical board level is just the tip of the iceberg, however. “The source of the bleeding is the ineffective systems of care that cause moral injury to health care workers who want to do better for their patients,” Dr. Simmons noted.
For example, consider the burden of prior authorization. A recent study found that new prior authorization on an established anticancer drug increased the odds of discontinuation and delayed care. “I imagine that happens a lot in oncology,” Dr. Simmons said. “We’ve got to streamline these administrative burdens for health care workers so that they can diagnose, treat, and provide compassionate care, which is what they are best at.”
Beyond going head-to-head with payers, other administrative and bureaucratic burdens such as onerous documentation requirements also keep oncologists from doing their work as caregivers. A 2023 analysis of electronic health record use found that oncologists have a higher burden than other specialties. “Inefficiencies in the system are cumulative for oncologists, and our work points to some potential areas to reduce inefficiency and potentially reduce burnout,” Sumi Sinha, MD, lead author of the study and a clinical instructor in the Department of Radiation Oncology at the University of California, San Francisco, told OBR previously.
What can be frustrating to many is that solutions to various administrative burdens at the health system level are already known. Human scribes, artificial intelligence assistance, and more robust team-based models of care could reduce the burnout and moral distress that often lead to depression, anxiety, and suicide among oncologists and others.
Because administrators often balk at the price tag on new software or new hires that these changes would demand, the American Medical Association (AMA) has created calculators that show how avoiding these changes can come at an even higher price. The calculators demonstrate the cost of turnover resulting from burnout when changes are not made, as well as the estimated savings from proactive interventions.
The AMA, the Dr. Lorna Breen Heroes’ Foundation, #FirstResponders First, and several other groups have partnered on the ALL IN campaign, which seeks to redesign workplace environments to prioritize clinician well-being. The project has signed up various organizations, including Northwestern Medicine and the University of Texas Cizik School of Nursing, that now have programs in the works to prioritize clinician mental health. In December 2023, the state of Virginia signed on, and the campaign suggests that other states are poised to do the same.
Oncologists Sharing Mental Health Stories Is Crucial
Systemic changes such as destigmatizing license requirements and reforming administrative procedures will have the most far-reaching effects but will also take time. But oncologists can make a difference for themselves and others simply by speaking out. This is critical to eliminating barriers in seeking mental health care, says Kelly Irwin, MD, president-elect of the American Psychosocial Oncology Society.
“We need to normalize seeking treatment by having leadership model and share those stories – ‘I was depressed. I took this medication. I see my therapist twice a week, and it’s essential for me to keep working’ – these stories are not commonly shared, and they need to be,” says Dr. Irwin, who is a psychiatrist at the Massachusetts General Hospital Cancer Center.
That’s what community oncologist David N. Oubre, MD, tries to do. The Louisiana-based physician saw the first signs of what he considered to be dysthymia when he was a medical resident some 30 years ago. He managed the bouts of low mood for nearly 20 years with exercise, good sleeping habits, and staying social. He said that by the time he hit his mid-40s, the periodic episodes of mild depression had become an uninterrupted, deep, and abiding sadness that kept him awake at night, affected his relationships, and touched every aspect of his life.
“It was like that every day,” he said. “I finally went to my doctor at that point, and said, ‘It’s time.’ I needed to go on medicine for it.”
For the last 10 years, Dr. Oubre has taken antidepressants and isn’t afraid to talk about it. “Depression is a disease just like hypertension, heart disease, and cancer. We talk about those things openly, yet for some reason, people don’t want to talk about their depression, which is real and based on pathology and physiology,” he said.
“If I can be open about it, maybe it will encourage others to be open about it.”
Dr. Oubre acknowledges that openness like his isn’t risk-free. “I haven’t experienced this, but if you go to a primary care doctor who refers patients to you, and you tell them you’re struggling with mental health problems, you certainly might worry that the physician won’t want to send you patients in the future.”
“This Is Real Stuff That Has an Impact”
A 2023 study on burnout that included more than 5,000 physicians showed that doctors were more interested in improvements in staffing, workload, and work environments and were less interested in wellness programs and resilience training. The latter interventions put the onus on the doctors.
“We’re moving away from putting the responsibility for well-being entirely on the individual and focusing on the system’s moderators of well-being: your compensation, your space, your processes,” said Lourival Baptista-Neto, MD, a psychiatrist and chief well-being officer at the Columbia University Irving Medical Center. “This is real stuff that has an impact,” he added.
Columbia University has taken strides to normalize mental health challenges among doctors. The university launched CopeColumbia in response to the acute and collective mental health crisis among clinicians early in the pandemic.
The program offers free and confidential mental health services. Care typically starts with a 30-minute Zoom session, for which there is no billing or charting. These sessions can provide a fast connection to more formal care for those who need it. About one in four people do, Dr. Baptista-Neto added. The program also provides training to individual units, such as the oncology department, so that leadership in these departments can create their own mental health and wellness support for staff.
“After the second year, it became part of the medical center’s operating budget and was built into the Office of Well-Being. Now it’s a resource available to all employees that’s not going away,” said Dr. Baptista-Neto.
This is just one example of the sort of institutional interventions that can make a difference. Opportunities to be together and lean on each other go a long way to supporting the mental health of healthcare professionals, noted Sarah Conning, LCSW, a California-based oncology social worker and immediate past president of the Association of Oncology Social Work.
“Sometimes just being together to discuss a difficult case can be helpful,” she said. “Of course, allowing time for health care providers to go to therapy if they need it [is important], but I tend to think that things that reduce isolation, bring people together, and build connections could be even more valuable.”
Ultimately, it may not take a wildly creative solution to help turn the tide when it comes to oncologists’ mental health. Simply having more time may help solve many of the problems, Conning says. In a medical specialty that treats some of the sickest patients, at the most difficult time in their lives, oncologists are expected to move as quickly from one patient to the next as any other doctor would.
Although carving out space for it may be a challenge, more time with patients could be a key antidote. “Although that may mean you see more of the heaviness and sadness of your patient’s situation, it also puts you more in connection with them,” Conning said. “People need human connection, and to be in a profession with exposure to so much human suffering only increases that need for connection.
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