By way of tradition, our current system of oncology training exposes fellows to vast amounts of suffering in their first year. As fellows, we see dying patients with cancer in the hospital; we see the third-opinion, last-ditch referrals; we see most newly presenting patients; and we spend the hours of our days experiencing the tragedy of others: the incomprehensible shock of a new diagnosis and the searing loss of death.
Daniel R. Richardson, MD, MA
In this baptism by fire, we develop habits of managing patient suffering. We instinctively build barriers around our hearts by being careful not to “get attached” and staying “objective.” We insulate ourselves enough to be functional in our next clinical encounter and remain composed in front of superiors. Developed beneath our conscious mind, these habits are absorbed from the surrounding culture rather than being explicitly taught.1
As an oncology community, we need to ask several critical questions about our enterprise: How are we training our fellows to handle the immense amount of suffering they are experiencing? How is our culture shaping their identity as oncologists? And are we instilling in them a purpose within oncology that can sustain them throughout their careers?
Moral Formation and Identity Development
Broadly, oncology fellows are conditioned to become either academic or clinical physicians, and we quickly learn the values and currency of each. We convince our directors, employers, and peer reviewers that we are worthy to invest in. We learn that the value we bring to our employer is our ability to bring in revenue or grant dollars.
The pursuit of these roles—academic or clinical—in the latter years of fellowship provides an escape from the gravity of patient suffering felt during our first year. Within these roles, we experience success and praise, in contrast to our clinical encounters, which seldomly result in professional affirmation. Although we cannot control who responds to chemotherapy or who will die in the intensive care unit, we can control how clinically proficient we become or how productive we are.
The problem arises when one of these roles, either productive academician or proficient clinical practitioner, becomes our core identity as an oncologist—displacing our primary call to serve patients. Although necessary, these roles are not sufficient to sustain us in the midst of patients’ suffering. Instead of drawing near to our patients, we tend to functionalize them. Clinical encounters may become a means to an end—either to generate “relative value units” or satisfy the administrative quota. We subconsciously adopt language that betrays our primary calling; we talk about how many patients we “have to” see or how many days of service we “have to” do. This is who we are becoming morally.
No one went into oncology to generate relative value units. We came here instead to give our lives in the service of others. We wrote about it in our med school applications and affirmed it on graduation. Our vision and purpose for entering medicine was clear—sacrifice so that others may benefit. Sadly, this vision has been largely lost among other developing roles in oncology.
Reclaiming Our Vision of Service
Oncology training programs play a critical role in the moral formation of fellows by establishing normative culture. Moral formation is the process of cultivating values, habits, and actions as part of a broader identity. In addition to providing necessary
technical and didactic training, fellowship programs are the entrance for trainees into the oncology culture.
Instead of passively facilitating this process, programs could become centers for moral growth, where virtues are recognized, discussed, and ingrained. They can expose values and habits within the broader culture that are praiseworthy, as well as those that are shameful and damaging. In doing so, programs recapture their central position of developing fellows with a sense of vision and calling.
A curriculum for moral formation should be envisioned and developed at each fellowship program. Dedicated curricular interventions could instill virtues, not only of resilience, but of patience, kindness, goodness, compassion, empathy, hope, and joy. Programs should provide the space, opportunity, and protected time to remember and reflect on our shared vision of service to patients. Contemplation of this immense privilege, along with remembering the legacy of past oncologists, will engender in us humility, gratitude, and joy.
“Our vision and purpose for entering medicine was clear—sacrifice so that others may benefit. Sadly, this vision has been largely lost among other developing roles in oncology.”— Daniel R. Richardson, MD, MA
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Identifying champions who can cast vision and provide leadership will be essential. These champions should serve as mentors for fellows and advisors to programs. What good would be achieved if fellows could spend time in observation of their practices and reflection on how to become more like them. Other components of the curriculum should include dedicated training, for example, in end-of-life communication, cultural competency, and rapport building. We have implemented this curriculum at our institution and urge others to do so as well.2
Sacred Space
The reason for this call is straightforward: Our suffering and dying patients need us. Their suffering is an open door to a sacred space that only we, as oncologists, can enter. They need us to walk in and tell them that we see their pain. We have been here before, and they can lean on us. We have the unique opportunity to occupy this sacred space, to love patients in the depths of their suffering.
Caring for patients in this way will be tinder to our souls—each encounter sparking joy and satisfaction deep within us. Those who develop these habits will, in fact, never burn out. Those who fail to experience this sacred connection between patient and doctor are at the greatest risk. Rather than burning out, they will fail to burn at all.
Conclusion
Many wellness interventions have focused on improving systems-based problems, and rightfully so. However, failing to recognize aspects of burnout as a problem of identity formation may mislead us into aiming our interventions too shallowly, into the branches and not into the roots. The oncology community and training programs in particular have an opportunity to direct the moral formation of the next generation of oncologists. Thoughtfully embracing this profound responsibility may help develop oncologists who find joy in each clinical encounter and combat the ongoing epidemic of burnout within our community.
Dr. Richardson is a Fellow in the Division of Hematology & Oncology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill.
DISCLOSURE: Dr. Richardson has received research support from the Conquer Cancer Foundation. The project to develop a new curriculum was supported in part through the National Research Service Award Post-Doctoral Traineeship from the Agency for Healthcare Research and Quality.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.
REFERENCES
1. Hafferty FW, Franks R: The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med 69:861-871, 1994.
2. Richardson DR, Winzelberg G, Rosenstein DL, et al: Development of an ‘Art of Oncology’ curriculum to mitigate burnout and foster solidarity among hematology/oncology fellows. 2019 ASCO Annual Meeting. Abstract 10507. Presented June 1, 2019.
