October 24, 2019
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Depression in oncologists: For many, a closely guarded secret

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Oncologists, and physicians in general, are trained to strive for excellence, remain strong and resilient in the most difficult circumstances, and devote themselves to the patients who depend on them.

When balanced with self-care and a healthy mindset, these attributes make for an exceptional physician. When taken too far, however, they can lead to burnout, depression and even suicide.

It is estimated that between 300 and 400 physicians — the equivalent of a large graduating medical school class — die of suicide each year. The high rate of suicide is driven by a variety of factors culminating in major depression, but often, the fatal component is reluctance to seek help.

“Physicians are less likely to seek mental health care than the general public, especially the highly educated general public,” Anthony L. Back, MD, professor of medical oncology at University of Washington Medical Center and co-director of the UW Center for Excellence in Palliative Care, told HemOnc Today. “Physicians have been trained to be perfectionists. They’ve been trained not to ever show any weakness, and they think of mental health issues as weakness.”

Oncologists, who frequently deal with death and distressed patients and family members, may be especially prone to depression.

HemOnc Today spoke with medical oncologists and psycho-oncologists about the prevalence and causes of depression and suicide among physicians, the differences and similarities between depression and burnout, and how a little resilience can go a long way to help oncologists overcome a negative mindset.

‘Largely ignored and understudied’

The stigma attached to depression makes it difficult to gauge its prevalence among physicians.

Michelle B. Riba, MD, MS
Michelle B. Riba

According to Michelle B. Riba, MD, MS, director of the PsychOncology Program at University of Michigan Rogel Cancer Center, conclusive data on this topic are lacking, especially when considering oncologists specifically.

“There are not really good data on oncologists per se, but more and more studies are being done now to track medical students over a period of time,” Riba told HemOnc Today. “A colleague of mine here in the department of psychiatry, Srijan Sen, MD, PhD, and other colleagues have been doing this for about 13 years now.”

Sen leads the Intern Health Study, a longitudinal cohort study evaluating stress and mood among medical interns across the United States. The study enrolls more than 3,000 new interns annually.

In one analysis from the study, published in Academic Medicine, Mata and colleagues found that one in four medical interns met the criteria for diagnosis of clinical depression.

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In another investigation within the Intern Health Study, Pereira-Lima and colleagues reported that institutions with the most stressful training rotations, least useful guidance and longest hours had the highest rates of depression among interns.

Additionally, a meta-analysis of 31 cross-sectional studies — also conducted by Mata and colleagues — found a 28.8% summary estimate of depression or depressive symptoms among resident physicians. Results also showed an increase in depressive symptoms among residents over time, with a longitudinal analysis showing a significant increase in depressive symptoms among trainees after the start of residency.

Although data on depression among oncologists are sparse, there seems to be an indication that oncologists may suffer more from burnout than other physicians, Riba said.

“Generally, oncology physicians tend to have increased stress, and studies in other countries about burnout show it does tend to be high in oncology clinicians,” she said.

Oncologists often deal with the depression and anxiety of terminally ill patients and their families, a situation that likely compounds their own sense of discouragement, according to Fay J. Hlubocky, PhD, MA.
Oncologists often deal with the depression and anxiety of terminally ill patients and their families, a situation that likely compounds their own sense of discouragement, according to Fay J. Hlubocky, PhD, MA. “On a daily, if not hourly, basis, oncologists must bear witness to and grapple with challenging situations involving seriously ill patients and distressed caregivers,” she said.

Source: University of Chicago Medicine.

Although the available evidence suggests a higher prevalence of depression and burnout among oncologists, this information is highly variable and incomplete, according to Fay J. Hlubocky, PhD, MA, clinical health psychologist in the department of medicine at University of Chicago.

“Oncologists experience elevated levels of depression and anxiety compared with other internal medicine colleagues, yet the mental health of oncologists has been largely ignored and understudied,” Hlubocky said in an interview with HemOnc Today. “According to existing research, prevalence rates vary and depend on the type of oncologist, practice setting, assessment tools and countries of practice where oncologists were studied. The same factors hold true for oncology nurses, who also experience high levels of depression and anxiety.”

According to a 2019 ASCO Educational Book article by Daniel C. McFarland, DO, medical oncologist at Memorial Sloan Kettering Cancer Center, and colleagues — including Hlubocky and Riba — oncologists face high levels of depression while, paradoxically, often having high job satisfaction.

“This may speak to the nature of the work and how most oncologists feel about providing this type of meaningful medical care,” they wrote. “Although oncologists provide treatments that can enhance life or ameliorate the complications of cancer, they work on the razor’s edge of life and death in a way that is not entirely translatable across disciplines.”

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Stressors unique to oncologists may include dealing “intimately with providing life, mitigating complications and negotiating with death,” McFarland and colleagues added.

Negotiating with death can encompass a variety of stressors, including:

  • dealing with distressed relatives;
  • coping with patients who suffer during treatment;
  • feeling disappointed with treatment options;
  • having unrealistic expectations;
  • delivering bad news, and often having to communicate with distressed patients; and
  • worrying about patients outside of work hours.

Persistent depression and burnout can have a variety of consequences for physicians, ranging from chronic health conditions to poor job performance.

“Oncologists remain on the front line between life and death,” McFarland and colleagues wrote. “Although this may not be directly associated with burnout ... it contributes to depression and subsequently to suicide. Our culture is death-denying, which may contribute to the loneliness that physicians can feel in their work.”

The problem of ‘detached concern’

The hesitancy to show perceived “weakness” likely has led to an underreporting of depression among oncologists and other physicians.

Daniel C. McFarland, DO
Daniel C. McFarland

A sort of stoicism about mental health is ingrained in physicians early on, McFarland told HemOnc Today.

“From day 1 of medical school training, you’re putting yourself in the role of the healer,” he said. “The problem is that, as a doctor, you feel like it undermines your role as a healer when you admit to having a problem.”

Although physicians might be less likely to acknowledge their depression, their rates of suicide compared with the general public tell a different story.

According to the ASCO Educational Book article, the rate of suicide among male physicians is 1.41 times that of the general population. Female physicians show an even greater disparity, with a relative risk for suicide 2.27 times that of their nonphysician female counterparts.

Additionally, physicians, with their extensive knowledge of the human body, have a substantially higher rate of suicide completion than the general public.

Given these data, the ongoing resistance to mental health care among clinicians can be especially harmful. During a time when much of society has grown more comfortable discussing mental health, the culture of physicians is a notable outlier.

In a study published in General Hospital Psychiatry, Gold and colleagues surveyed female physicians aged 30 to 59 years across the U.S. The researchers found that 50% of respondents felt they met the criteria for mental illness but had not sought treatment.

The qualitative responses to the survey were revealing in terms of the consequences of acknowledging mental health issues.

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“I have been discriminated against in a department after disclosing my history of well-treated depression to my department chief,” one respondent wrote.

“I never share my mental health history with medical professionals, since I know the stigma involved. I always lie on my health intake forms,” another wrote.

One clinician reported leaving the profession due to the repercussions she faced from disclosing a mental health issue.

“All of my fears were realized when I did report it,” she wrote. “I was placed in a very strict and punitive [partial hospitalization program] that didn’t allow me to take meds written by my doctor for anxiety and insomnia. I am now not practicing at all because of this.”

Such studies show that the stigma around mental health remains deeply and overwhelmingly embedded in physician culture.

McFarland said part of this toxic fear of showing weakness may be rooted in the “detached concern” model of medicine prevalent in the 20th century.

Proposed in 1959 by sociologist Renée Fox in her book, Experiment Perilous, detached concern initially was intended as a means for physicians to separate emotion from objectivity when dealing with patients. Fox wrote that detachment and concern should remain in a “dynamic balance,” so that the physician is objective while concerned enough to provide compassionate care.

However, Cadge and Hammonds wrote in a 2012 report that this philosophy often has been interpreted as promoting emotional concealment, or “putting emotions on ice.” Rather than viewing detachment and concern as dichotomous, health professionals often are taught to put detachment before concern, they wrote.

“Physicians approached patients with ‘detached concern,’ which means you’re concerned, but you’re not showing it, or you’re not showing much of it,” McFarland said. “The problem with that is, as human beings, we just require a little bit more.”

Burnout or depression?

Although it is not uncommon to hear the words “burnout” and “depression” used interchangeably, experts said it is important to understand the key differences between the two.

The term “burnout” was first defined in the 1970s by psychologist Herbert Freudenberger as “the consequences of severe stress and high ideals in the ‘helping’ professions.”

Although burnout is a specific workplace-specific phenomenon, depression is seen in all areas of a physician’s life. According to Hlubocky, between 32% and 78% of practicing oncologists worldwide experience symptoms associated with burnout.

“Burnout is a work-related clinical syndrome that manifests as chronic occupational and interpersonal pressures persisting over time,” Hlubocky said. “It is characterized by three core dimensions: physical and emotional exhaustion, depersonalization and cynicism.”

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Depression, conversely, is a medical diagnosis with symptoms that are not confined to the workplace.

“Major depression is a global sense of, ‘I’m worthless, I’m terrible. Nothing in my life is going well,’” Back said. “That extends to all parts of your life, not just the work part.”

Hlubocky said a critical contributor to oncologist burnout is the organizational environment and occupational stress of the job.

Although burnout can be alleviated by removing the stressful workplace situations, depression will persist regardless, McFarland said.

“In theory, if you were to just completely change that person’s job around or tell them to stop working, a depressed person is not going to get better,” he said. “If it’s truly burnout, they’re going to improve.”

Although the two terms are distinct, some studies have indicated a relationship between burnout and depression.

In a 2019 cross-sectional study that surveyed 269 medical students, Fitzpatrick and colleagues calibrated burnout scores from the Maslach Burnout Inventory-Student Survey to the likelihood of depression “caseness,” based on a score of 6 or higher on the Beck Depression Inventory-Fast Screen. They classified burnout scores as conferring low risk (less than 25%), intermediate risk (25%-50%) and high risk (> 50%) for depression.

Results showed a 39% (95% CI, 33-45) rate of depression caseness. Moreover, participants in the low burnout category had a 13% overall prevalence of depressive symptoms, whereas those in the intermediate category had a 38% prevalence and those in the high burnout category had a 66% prevalence (OR for one tertile increase in score = 2; P = .011).

“Over time, what has been found is that burnout in oncologists often turns into depression,” Back said. “It starts out with your professional life and then consumes your whole life. You start out feeling terrible at work, but these are people who are spending 50 to 60 hours a week at work, so it starts to globalize to every part of their life.”

The relationship between burnout and depression also can be bidirectional, Hlubocky said.

“Psychiatric disorders such as depression and posttraumatic stress disorders are both precursors to the development of burnout, as well as the consequences of unaddressed burnout,” she said. “Burnout and depression are related in that the greater the severity of oncologist burnout, the more likely it is for one to develop clinical depression.”

McFarland said depressed physicians may still derive some sense of meaning and purpose from their high-stakes profession.

“It’s interesting, because it doesn’t correlate necessarily with job satisfaction,” he said. “It’s a setup where some oncologists may be more prone to depression but probably benefit from the rewarding nature of the work they do.”

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Facing death

Compared with other types of physicians, oncologists must constantly face a devastating reality — many cancers remain incurable, eventually leading to the deaths of the patients they treat.

“Witnessing patients and families who are dealing with death and multitudes of losses is challenging,” McFarland said. “We have to develop our own clear sense of emotional awareness.

“The key is self-awareness, so that you can make adjustments and step back from the situation to gain perspective as necessary,” he added. “We’re human beings. But, part of the skill set of dealing with patients who are seriously or terminally ill is recognizing when your own feelings are active.”

Although oncologists may become accustomed to dealing with death on some level, it isn’t the type of situation anyone can repeatedly endure without any impact, Back said.

“That is something that is constantly in the background and, if you dig deeply into what is stressful, you will find it is stressful to watch a lot of nice people get sicker and die despite your best efforts,” he said. “I think many oncologists would say, ‘Yeah, I’m used to that; it’s part of my work,’ and yet it is a challenging place to be, no matter how together you are.”

Hlubocky added that oncologists often must deal with the depression and anxiety of terminally ill patients and their families, a situation that likely compounds their own sense of discouragement.

“On a daily, if not hourly, basis, oncologists must bear witness to and grapple with challenging situations involving seriously ill patients and distressed caregivers across the cancer trajectory,” she said. “Many patients experience a state of psychological distress a crisis, whether it be at the time of diagnosis, treatment transitions or, especially, at the end of life. Oncologists become witnesses to this trauma and are charged with effectively communicating the complex biomedical information, bad news, treatment failures and impending death.”

Due to repeated exposure to this suffering, oncologists may find it difficult to cope, becoming vulnerable to depression, and this emerging depression often represents the final stage of the burnout cycle, Hlubocky said. However, she said communication skills training has shown some efficacy in preparing oncologists to face these challenges and protect them from depression and burnout.

“Bereavement services also are vital and should be routinely offered to all clinicians suffering loss,” she said. “We must all serve as well-being advocates for our oncology colleagues in order to battle this epidemic.”

The power of resilience

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The best way to foster a healthier future for oncologists is for senior oncologists to lead by example, according to Back. However, he said the stoic mindset of medicine is, to an extent, a generational problem.

“Senior physicians grew up in a world where nobody asked how you felt and nobody cared, honestly, and therefore these physicians have developed survival coping strategies,” he said. “Revising those strategies is a hard thing to do at any age, but I think it’s a bit harder for older physicians, because they’ve been doing it for so long. That’s how they’ve been surviving.”

Oncology practice has begun to change, however, with modern physicians facing new administrative demands and time constraints. For these increasing responsibilities, the old approach of “powering through” without help may not be equal to the task.

“We need to figure out how to change that modeling,” Back said. “It is important to help doctors recognize that lots of people are encountering this, not just them, and there are things that can help, especially with early intervention. There are people who recover. These are important things for practicing physicians or physicians-in-training to hear.”

Rather than aiming for perfection or invincibility, Back said the goal is resilience, a long-term survival skill that cannot be achieved by avoiding problems. He said some institutions are beginning to offer resilience training, which includes mindfulness and cognitive behavioral skills.

“We want to change the message from ‘You only do this if you’re weak’ to ‘Lots of people do this at different times in their careers to keep themselves sharp,’” he said.

Riba said University of Michigan offers facilitated care at the medical school, with designated clinicians and faculty.

“These clinicians see students and residents,” she said. “Now we’re investigating telepsychiatry so that people don’t necessarily need to be traveling to a clinic or office to receive treatment, making it easier for busy clinicians to receive care and keep appointments.”

Group therapy programs and retreats, such as the “Being with Dying” retreat taught by Back at Upaya Zen Center in Santa Fe, New Mexico, are becoming increasingly available. Many institutions also are investigating reduced hours, optimizing workflow and cognitive behavior interventions.

Hlubocky said oncology leaders must reconsider the burden of unnecessary administrative tasks. She said programs such as physician champions/mentors, communication skills training and team-based care can improve the quality of a physician’s work.

“Peer support programs should be developed to foster a community of support,” she said. “Seeking professional help for mental health issues should be encouraged through referral, if not provided by the organization, without fear of repercussion.”

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McFarland said ignoring signs of depression is likely to have professional consequences.

“Physicians would do well to have their depression treated, because there are implications further down the line, like doing less of a stellar job or causing harm to your work relationships,” he said. “This definitely outweighs the stigma of getting help.”

However, physicians may remain reluctant to seek help until oncology leadership signals an acceptance of mental health struggles. According to Hlubocky, new oncologists will only feel comfortable discussing depression if they see this modeled by their superiors.

“The oncology community, led by cancer leadership, has an absolute duty and obligation to acknowledge the mental health issues that oncologists, nurses and other oncology clinicians experience,” she said. “We must normalize and speak of mental health issues to minimize the stigma that presently exists.” – by Jennifer Byrne

Click here to read the POINTCOUNTER, “Should psychotherapy be mandatory for medical students/residents?”

References:

Cadge W and Hammonds C. Perspect Biol Med. 2012;doi:10.1353/pbm.2012.0021.

Fitzpatrick O, et al. BMJ Open. 2019;doi:10.1136/bmjopen-2018-023297.

Freudenberger HJ. Burn-Out: The High Cost of Achievement. Garden City, NY: Anchor Press; 1980.

Gold KJ, et al. Gen Hosp Psychiatry. 2016;doi:10.1016./j.genhosppsych.2016.09.004.

Mata DA, et al. JAMA. 2015;doi:10.1001/jama.2015.15845.

Mata DA, et al. Acad Med. 2016;doi:10.1097/ACM.0000000000001227.

McFarland DC, et al. Am Soc Clin Oncol Educ Book. 2019;doi:10.1200/EDBK_239087.

Pereira-Lima K, et al. Acad Med. 2019;doi:10.1097/ACM.0000000000002567.

For more information:

Anthony L. Back MD, can be reached at 325 Ninth Ave., Box 359762, Room 10CT-23, Seattle, WA 88104; email: tonyback@u.washington.edu.

Fay J. Hlubocky, PhD, MA, can be reached at 5841 Maryland Ave., Chicago, IL; 60637; email: fhlubock@medicine.bsd.uchicago.edu.

Michelle B. Riba, MD, MS, can be reached at 4250 Plymouth Road, SPC 5769, Ann Arbor, MI 48109-2700; email: mriba@umich.edu.

Daniel C. McFarland, DO, can be reached at 500 Westchester Ave., West Harrison, NY 10604; email: danielcurtismcfarland@gmail.com.

Disclosures: Riba reports serving as senior editor of books for Springer and Workplace Mental Health. Back, Hlubocky and McFarland report no relevant financial disclosures.

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