Burnout By Specialty: Oncology

Burnout is a term that echoes throughout the medical field, yet its manifestations can vary significantly across specialties. In oncology, where deep emotional connections with patients are commonplace, burnout takes on unique characteristics. In this episode, we delve into the insights shared by three experienced oncologists: Dr. Tiffany Troso-Sandoval, Dr. Laila Agrawal, and Dr. Eleny Romanos-Sirakis, in a discussion about the realities of burnout in their field. Here’s what every healthcare professional needs to understand about burnout in oncology.

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Takeaways:

- Recognize Burnout Symptoms: Understanding how burnout manifests in oncology can help professionals identify their own struggles and seek support.
- Foster Supportive Relationships: Building a supportive community among healthcare providers can help mitigate feelings of isolation and burnout.
- Advocate for Resources: Engaging with healthcare systems to improve resource availability and reduce administrative burdens is crucial.

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Transcript

Mary Remón: Thank you everyone for joining this series, Burnout by Specialty. Today, we welcome three oncologists for our episode, which is hosted by Doctors on Social Media. My name is Mary Remón, and I'm a licensed counselor and a coach for physicians. And I'm really excited and grateful today to introduce Dr. Laila Agrawal, Dr. Tiffany Troso-Sandoval, and Dr. Eleny Romanos-Sirakis. Let's start with brief introductions.

Tiffany Troso-Sandoval: Hello everyone, thank you so much for having me. My name is Dr. Tiffany Troso-Sandoval. I go by Dr. Troso. I am a medical oncologist. I specialize in breast and gynecologic cancers. I have been in this space for well over 20 years. I worked at Memorial Sloan Kettering for 25 years after finishing my fellowship there. I used to joke that I did residency at New York Hospital and medical school at Cornell, so I ate out of the same deli for like 20 years.

I have since retired. I had a medical issue of my own. I have started my own companies, which are for empowering and educating women with breast and gynecologic cancer, called Winning the Cancer Journey. And I do second medical oncology virtual opinions under a company called Second Look Oncology. So I have lots of different things to share with you and I'm so happy to be here. Thank you.

Mary Remón: Thank you, Dr. Troso. Dr. Agrawal, welcome.

Laila Agrawal: Thank you. I'm Dr. Laila Agrawal. I'm a medical oncologist. I specialize in the treatment of breast cancer and I'm located in Louisville, Kentucky. And currently we're under a lot of snow, which is not typical in Louisville. So enjoying a little snow day.

Mary Remón: Thank you. Welcome, Dr. Romanos-Sirakis.

Eleny Romanos-Sirakis: Hi, thank you so much for having me. My name is Dr. Eleny Romanos-Sirakis. I am the Director of Pediatric Hematology and Oncology at Northwell Health Staten Island University Hospital. I have been at this hospital for almost 15 years. So again, I am also a native New Yorker and I'm very happy to be here today. Thank you.

Mary Remón: Thank you all for joining in this conversation about burnout in oncology. So I'm going to start by asking you, Dr. Agrawal, what does burnout look like specifically in oncology?

Laila Agrawal: I think that just as in many different medical specialties, it's really multifactorial and there are many different ways that it can manifest and many different reasons for it. I think that we all share with other medical specialties the burdens of administrative tasks and fighting to get the care that we think our patients need, multiple barriers that are coming at multiple different levels, staffing shortages, all of these different things are shared.

But in oncology, I feel that we also have a unique stance where we really have quite long-term relationships with our patients, where we do see them very frequently. And we're able to develop close relationships and bear witness to a lot of suffering in many different forms, and high acuity, life-threatening conditions, and just a very high volume of that often.

Mary Remón: Thank you for that. Dr. Romanos-Sirakis, in your opinion, what part of the job can be most draining for oncologists?

Eleny Romanos-Sirakis: I think for oncologists there is really a high emotional intensity associated with being an oncologist. And for me, especially being a pediatric oncologist, we are especially emotionally invested in the care of the patients. And we become connected with not only our patients, but also our families. It's important to note that we often meet families on what they would probably consider one of the darkest and most fearful days of their lives. Hearing that your child has cancer is a very, very difficult day for a lot of our families. And we connect with them on that day and we walk with them through the struggle of seeing their child sick and oftentimes needing a lot of recovery time. And this is a very difficult path for many of these patients and families to traverse.

Mary Remón: And I can only imagine how draining that must be when you're caring so deeply about people and children especially in life-or-death situations.

Eleny Romanos-Sirakis: Absolutely. No one wants to see any child sick or struggle. And these can be very, very sick children that we care very deeply for. And we want to see them recover and get back to just being children and having their usual typical play and go back to school and do their normal activities.

Mary Remón: Thank you. Dr. Troso, what do you think people outside of oncology don't see? What is it that we don't get when it comes to what's unique in terms of the pressures?

Tiffany Troso-Sandoval: Well, I think that both Dr. Romanos and Dr. Agrawal touched on some of the very important aspects of it. I think that in many forms of medicine, you do form deep bonds with your patients and their families, as opposed to perhaps a surgical subspecialty where the patient is basically operated on and then perhaps handed off or is cured or what have you.

I think the long-term relationships within medical oncology in particular are substantial. And as part of my practice, it was very common for my patients to know pretty much everything about, not everything, but a lot about me and my children. They would ask me, how did Gabriella's soccer game go last week? I know you were heading to the varsity playoffs, or something. And likewise, I would ask them, how was your daughter's recital, or what have you?

And it was very much part of my practice to be not just their physician, but also their comrade. Not their friend, but their comrade, in that they felt very secure and comfortable, especially because I specialized in women. I find that it's really one of the reasons I'm drawn to women's oncology, because I really can relate to other women and I enjoy helping them empower themselves and helping them understand what's really important during a very difficult journey.

So when you have to give very bad news, for example, to a patient that you have become extremely emotionally connected to, there's this line that you have to draw because they don't want me to cry. They want to see my sympathy. They want to see that I care, but I need to be strong. And there are many times that I've been composed and compassionate and kind, and then once I leave the room, I'll go to the bathroom and cry just because I had to have an emotional release so I could be present and fully cognizant for the next patient.

That's just a couple of things. I think also what people don't necessarily see about medical oncology is the complexity of the care that we provide. Oftentimes in medical oncology, we're playing, I called myself, the point guard. I would be handling half their internal medicine care, their pain management, their psychiatric care.

My mantra was that I'll take care of the first level. I will take care of giving you the first line of blood pressure medicine. I'll start you on the SSRI for depression and I'll give you the Percocet if that's appropriate in that situation. Once it gets more complex, and a patient has continued psychosis or things get more complicated than that, then I would refer to a specialist.

But I found that medical problems, especially in an oncology patient that was actively being treated, can't wait four weeks to see the psychiatrist or eight weeks to see the pain specialist in the palliative care clinic. I had to get them started.

So I think what people don't necessarily know outside of oncology is how many hats we actually wear. And the complexity of our visits often far exceeds a 20-minute slot. So I think oncologists are probably some of the worst offenders when it comes to running late in clinic because of all of those factors, the social and socioeconomic ones, and then all of these other medical issues that we're also dealing with in addition to the cancer and the chemotherapy or what have you.

So, long-winded answer, but I just don't think a lot of people know behind the door how much we actually do.

Mary Remón: Thank you for describing that so vividly. So many hats. Dr. Agrawal, think about system pressures. Where do they hit hardest in oncology?

Laila Agrawal: I think that one of the big issues is always going to be trying to get our patient the care that we think they need. And medicine these days is highly complex. There are multiple layers to it, whether it's insurance approvals, prior authorizations, denials for things that are standard of care, having to write medical necessity letters for guideline-consistent, FDA-approved, indicated therapies.

All of these things are barriers. Cost is another one. If we know that a medicine is the right one for a patient and then cost makes it inaccessible to that patient, that's another huge systemic issue that we deal with also.

So we're seeing patients in the clinic, but simultaneously during the day we're on the phone with insurance, we're writing letters, we're finding backup options when the optimal option is not available. So I think that also is very challenging when we know that the best treatment is out there for our patient, but it just can't get to that person.

Mary Remón: Can't imagine. Thank you. Dr. Romanos-Sirakis, what feels most unsustainable these days in oncology?

Eleny Romanos-Sirakis: I think it's the lack of resources, the lack of time, and the lack of future workforce in pediatrics in general. It's hard for me to pinpoint one answer to that question.

As beautifully said, same thing with pediatric oncology. We are constantly struggling with lack of resources. And in addition to serving as more than just an oncologist, we serve as more than just a physician. We wear many hats, even outside of the physician role. We're struggling to find resources that are often lacking and not available, or there's a very long wait for them. So this is difficult.

Dealing with insurance companies, even from the pediatric side, is a daily struggle, making sure that we can get our patients the care and medications that we deem medically necessary.

And then in pediatrics, we are facing a workforce struggle as well. People are not entering the pediatric subspecialty workforce as much as they were in the past. So we are struggling to make sure that we can fill those needs for the future generations of pediatric patients. So all in all, we have a few things that we're dealing with.

Mary Remón: Thank you. Dr. Troso, you've been in the field for a long time and—

Tiffany Troso-Sandoval: Amazing, since I'm only 30.

Mary Remón: You're 25, I don't know. So you must have some secrets. What is it that keeps people practicing?

Tiffany Troso-Sandoval: That's actually an interesting question for me because I actually left traditional clinical medicine after 25 years, which was almost like trying to re-identify who I was.

The thing that kept me in the field, even after I left MSK, is the fact that I love connecting with and helping people. It has to be a passion of yours. This is not just a job. It's a career. It's a calling, so to speak.

There is so much joy in explaining something to somebody that they didn't understand before, and now the light bulb goes on, and then they actually feel relieved once they have a better understanding of what is going on. And that's something that now in my new role I get to do a lot. So that's one of the things I really enjoy.

I've kind of traded the hierarchy of a big, powerful academic institution for less compensation, but probably more fulfilling, rewarding work because I am now really able to spend a lot of time knowing the patient, taking care of the patient, and covering all the things that we were talking about before.

I just find that it's a wonderful field to be in. It's a really tough one to practice in though.

Mary Remón: Sounds like it comes from a place of passion. Thank you. Dr. Agrawal, in thinking about all these things, what do you wish leadership understood?

Laila Agrawal: Certainly there are multiple different aspects where systems and organizations can support clinicians in oncology. One big one is improving workflow efficiency. Sometimes it feels like we're dealing with very heavy emotional issues, end of life, recurrences, and then suddenly we have to spend almost an equal amount of time clicking so many boxes just to try to get an order in. So I think improving workflow efficiency is a big one.

Creating healthy teams is another important one.

And I also think that another important issue is really being able to have clinician autonomy in terms of what will work best for their teams, their clinic, their patients, and in delivering the care.

Mary Remón: That's an important wish list. Thank you.

Laila Agrawal: Probably not going to get any of those things on the wish side. Not anytime soon, at least.

Mary Remón: Got to put it out there. Dr. Romanos-Sirakis, if one thing changed, what do you think would reduce burnout the most?

Eleny Romanos-Sirakis: I think we need more resources for our physicians. And I think that means something different for every physician. Listening to the physician themselves and getting a sense of what their needs are would help figure out what would make their day a little bit easier in their own clinical practice. Because obviously even amongst pediatric oncologists, we all work in different settings and have different needs for our patients.

But having more of a direct conversation with the physician to better understand their needs and resources, and really pouring more resources into what physicians need to get their work done and be able to do it with a little more ease and a little less time.

Laila Agrawal: Well said.

Tiffany Troso-Sandoval: I think as well. I also know you guys haven't mentioned this as much, but I personally was completely overburdened by the EMR. I had a particular problem because I had a visual issue, but I think that having a virtual scribe should be standard of care for physicians at this point.

I think it's very onerous to ask a physician to do all the things that we've been discussing and then try to document them in a meaningful way that is then useful to somebody else in the future and checks all the boxes to get the proper reimbursement back for your RVU.

I also think that alleviating a lot of the additional computer burdens, at least where I was, is crucial. They just kept increasing. All of a sudden we weren't writing notes on paper, we weren't taking symptoms from patients on paper, we weren't doing any billing on paper, the chemo wasn't on paper, our notes—everything moved to the computer. And it tripled the time it took to do all of those things per patient. And every time I turned around, there was another automated task on the computer that was added to my list of job requirements.

I think that, in and of itself, needs to be restructured. And I love the discussion that you guys had about workflow and improving each individual physician's ability to have a little more autonomy in how their workflow should be, and how you should be structuring their practice and how it best runs for them and their team. Because it's true, not everybody can work the way that person A does. I agree with that.

And then last, what I really want to tell you, Mary, is that I do not think it is at all going to be possible for us to continue and function at the level that we want to function with our current medical insurance setup. I think fee for service and all the billing levels and what have you are very complicated and are not serving the patients or the physicians. They're really only serving the insurance companies at this point.

So I think that all needs to be restructured. I don't know how it's going to happen, but I think that until that changes, our pathway in medicine is not going to be able to substantially change either.

Mary Remón: I feel what you're saying. Thank you. Dr. Agrawal, any advice for doctors going into oncology?

Laila Agrawal: I think the advice I would have is really to focus on the patients and the relationship with the patients and the ways that we're able to help our patients. Every day, truly, it's such an amazing profession to be in. Because every day, I have such amazing interactions with my patients.

And I think we really get to see an aspect of humanity that not very many people get to see. On a day where I may have to give bad news to a patient or have something very serious to talk about, they may turn to me and say, you know, I can't imagine how hard it is for you to have to do this every day. They reach out and show compassion to me at a time when they are going through such a difficult moment.

And I think just that glimpse into that human spirit is such a unique thing, such a privilege. There are a lot of hard things, for sure, but I think if we really focus on that human connection, that's really where the beauty is.

Mary Remón: So beautiful and touching. I have one final question for each of you. It's the same question, so think about it. How can we make oncology more sustainable? And this is for our listeners to wrap up and take home.

Dr. Romanos-Sirakis, any thoughts about how we can make oncology more sustainable?

Eleny Romanos-Sirakis: We as physicians have to take care of ourselves. And I think we need to remind ourselves to do that. Because I think for all of us as oncologists, whether you're a medical oncologist or pediatric oncologist, you are in this field because you're passionate about caring for these patients. We walk with them on this journey from diagnosis to hopefully recovery, in any step that is along the way. We walk them through these struggles and we couldn't and wouldn't do this if we didn't absolutely love what we do.

But I think we need to remind ourselves to take care of ourselves in the long term. I think in general, we have a culture of self-sacrifice in medicine where we glorify the overwork. And I think we need to think about that and really be able to care for ourselves so we can continue to care for our patients.

Mary Remón: Well said. Dr. Agrawal, how can we make oncology more sustainable?

Laila Agrawal: That was a wonderful point. And along the same lines, I think about not just oncologists, but all of the different disciplines and team members that work together for the patient. Really being able to have resources to support all of the clinicians who are taking care of patients with cancer, I think, is an important aspect to sustainability.

Mary Remón: Thank you. And Dr. Troso.

Tiffany Troso-Sandoval: I think that there are two things that I would like to say. One is that I think there has to be more pressure at the top, toward administration, where the tone is set. And perhaps that pressure needs to come from the medical boards or some sort of unifying body for physicians to make sure that administrators are paying attention and really understand what burnout is and where it comes from.

The doctor that's chronically late, or the doctor that doesn't get their notes in on time, or comes back from vacation and still seems frazzled, these are all signs. They're soft signs. Does that doctor get reprimanded, or does somebody need to look closer and see what's going on and why this doctor is acting this way? Because I really feel that a lot of physicians I can think of in the past have shown very clear signs. And again, instead of getting the support that they need, they would get in trouble, so to speak, which is counterintuitive to me.

And then the second thing I would like to say is that I think that maybe during fellowship or during training, we need to be taught as physicians how to care for ourselves and how to create boundaries, and how to learn to take care of ourselves. Because as Dr. Romanos mentioned, it's not ingrained in our culture. In our culture, you are supposed to be invincible. You're supposed to be unable to fall apart. But we're never taught how to take care of ourselves.

And it is so true that if we don't take care of ourselves, we can't really do a good job in this very deep, emotional, and highly intelligent-driven field if we're hurting inside. So I think that it needs to come from the top down as well as from the bottom up.

Mary Remón: Well said. Thank you so much for the important life-and-death work that you do, for putting your hearts out there, for everything you do despite all the challenges. Dr. Agrawal, Dr. Troso, Dr. Romanos-Sirakis, thank you so much for sharing your voices on today's show. And thank you to Doctors on Social Media for giving us this platform.