Grief’s Hidden Role in Oncologist Compassion Fatigue and Burnout

A professor of medicine at Harvard Medical School with over 20 years of experience at the forefront of palliative care at Dana-Farber Cancer Institute, Abrahm is also the author of Comprehensive Guide to Supportive and Palliative Care for Patients With Cancer, now in its fourth edition and a go-to resource for busy oncology and palliative care clinicians. Her website, www.janetabrahm.com, is a resource for oncology clinicians needing extra expertise in supportive and palliative care.

Oncologists experience high levels of burnout and compassion fatigue. Previously, levels were around 35%.¹ In a recent survey, 59% of respondents reported 1 or more symptoms of burnout: 57% reported high levels of emotional exhaustion, and 34% reported they “have become more callous” toward people.²

Long work hours, being required to see more patients, more time spent completing the electronic medical record, the COVID-19 epidemic, structural racism, institutional and gender bias (including in compensation), being exposed to death and dying of patients, and loss of physician autonomy all contribute.^1-3 The financial toll is estimated to be up to $4.6 billion annually.³

Previously identified mitigating factors focus on providing support for the practice, administration, patient care, and staffing,^1,3,4 as well as strategies to build resilience.^3-5 Identifying countertransference and processing disenfranchised grief have received less attention in preventing and treating burnout and compassion fatigue.

I reviewed literature from 2009 to 2024 that discussed countertransference, grief, burnout, and compassion fatigue among oncologists. The results revealed new strategies for preventing or reversing compassion fatigue and burnout. Oncologists may not be aware of their countertransference and disenfranchised grief, which contribute significantly to burnout and compassion fatigue.

Countertransference occurs when oncologists have an unusual attachment to patients because of similar age or background (ie, being of the same faith or a child of immigrants) or similarity to a loved one.⁶ Oncologists try harder to save these patients and find themselves falling into deeper despair when they die.

Disenfranchised grief arises when the loss is not socially validated, publicly mourned, or openly acknowledged.⁷ Deaths of those for whom they had countertransference, long-term patients, or young people, as well as unexpected deaths and unrealistic family expectations, all play a role in oncologists’ disenfranchised grief.⁸

Disenfranchised grief leads to compassion fatigue and all the symptoms of burnout; when grief is not processed, there is “nothing left” for the next patient or family.⁹ Oncologists may find themselves making rounds early in the morning, before visiting hours. Unprocessed memories of painful experiences partnering with palliative care in managing the needs of dying patients and oncologists’ previous feelings of grief, guilt, and helplessness may deter them from referring to palliative care again.^10,11

Qualitative studies indicate several strategies that complement those suggested by the American Society of Clinical Oncology clinician wellbeing task force.^5,8,9,12 Oncologists can partner with palliative care for patients when they recognize factors that trigger countertransference. Virtual visits with the palliative care clinician work as well as those conducted in person.¹³ To begin to process grief, oncologists can share it with office colleagues, make condolence calls, or send a card.¹² Establishing an office bereavement program that automatically sends materials at specified times after patients’ deaths with information about normal grief and offers of help for bereaved families can also be beneficial.¹⁴ The institution could also hold a remembrance service for clinical and administrative staff at regular intervals.¹⁵

When countertransference, guilt, and disenfranchised grief go unrecognized, they can contribute significantly to developing compassion fatigue and burnout among oncologists. Oncologists must believe they have not failed when their patients die; medicine has. By partnering regularly with palliative care, oncologists can learn to recognize signs and symptoms of countertransference in themselves or colleagues and learn how to not replace helplessness with guilt. By accepting help in acknowledging and processing their grief, whether others recognize it or not, and grieving together with staff and colleagues, healing can happen.

REFERENCES:

1. Shanafelt T, Dyrbye L. Oncologist burnout: causes, consequences, and responses. J Clin Oncol. 2012;30(11):1235-1241. doi:10.1200/JCO.2011.39.7380

2. Schenkel C, Levit LA, Kirkwood MK, et al. The state of professional wellbeing and satisfaction among US oncologists. JCO Oncol Pract. 2023;19(suppl 11):1. doi:10.1200/OP.2023.19.11_suppl.1

3. Hlubocky FJ, Shanafelt TD, Back AL, et al. Creating a blueprint of well-being in oncology: an approach for addressing burnout from ASCO’s clinician well-being taskforce. Am Soc Clin Oncol Educ Book. 2021;41:e339-e353. doi:10.1200/EDBK_320873

4. Hlubocky FJ. Attending to oncology team well-being. JCO Oncol Pract. 2022;18(8):541-542. doi:10.1200/OP.22.00432

5. Hlubocky FJ, McFarland DC, Back AL, et al. Development, feasibility, and acceptability of an oncologist group peer support program f rom ASCO’s clinician well-being task force. JCO Oncol Pract. 2023;19(8):669-675. doi:10.1200/OP.23.00068

6. Laor-Maayany R, Goldzweig G, Hasson-Ohayon I, Bar-Sela G, Engler-Gross A, Braun M. Compassion fatigue among oncologists: the role of grief, sense of failure, and exposure to suffering and death. Support Care Cancer. 2020;28(4):2025-2031. doi:10.1007/s00520-019-05009-3

7. Doka KJ. Grief: the constant companion of illness. Anesthesiol Clin. 2006;24(1):205-212, x. doi:10.1016/j.atc.2005.12.005

8. Granek L, Krzyzanowska MK, Tozer R, Mazzotta P. Difficult patient loss and physician culture for oncologists grieving patient loss. J Palliat Med. 2012;15(11):1254-1260. doi:10.1089/jpm.2012.0245

9. Granek L, Tozer R, Mazzotta P, Ramjaun A, Krzyzanowska M. Nature and impact of grief over patient loss on oncologists’ personal and professional lives. Arch Intern Med. 2012;172(12):964-966. doi:10.1001/archinternmed.2012.1426

10. Braun M, Hershkovitz TA, Melumad NM, Goldzweig G. The paradox: guilt as an antidote to helplessness among oncologists. Support Care Cancer. 2022;30(9):75457551. doi:10.1007/s00520-022-07196-y

11. Abrahm JL. Integrating palliative care into comprehensive cancer care. J Natl Compr Canc Netw. 2012;10(10):1192-1198. doi:10.6004/jnccn.2012.0126 12.

12. Granek L, Mazzotta P, Tozer R, Krzyzanowska MK. Oncologists’ protocol and coping strategies in dealing with patient loss. Death Stud. 2013;37(10):937952. doi:10.1080/07481187.2012.692461

13. Greer JA, Trotter C, Jackson V, et al. Comparative effectiveness trial of early palliative care delivered via telehealth versus in person among patients with advanced lung cancer. J Clin Oncol. 2024;42(suppl 17):LBA3. doi:10.1200/JCO.2024.42.17_suppl.LBA3

14. Abrahm JL, Cooley M, Ricacho L. Efficacy of an educational bereavement program for families of veterans with cancer. J Cancer Educ. 1995;10(4):207-212. doi:10.1080/08858199509528375

15. Morris SE, Kearns JP, Moment A, Lee KA, deLima Thomas J. “Remembrance”: a self-care tool for clinicians. J Palliat Med. 2019;22(3):316-318. doi:10.1089/jpm.2018.0395