On Being An Oncologist by MD Anderson Cancer Center

The University of Texas MD Anderson Cancer Center Program on Interpersonal Communication And Relationship Enhancement (I*CARE) Presents:

ON BEING AN ONCOLOGIST Reflections on the Personal Dimensions of Clinical Oncology A Workbook Companion to the Video Presentation by Megan Cole and William Hurt 2 nd Edition

by Walter F. Baile, M.D. Robert Buckman, M.D., Ph.D.

ON BEING AN ONCOLOGIST Reflections on the Personal Dimensions of Clinical Oncology A Workbook Companion to the Video Presentation by Megan Cole and William Hurt 2 nd Edition by Walter F. Baile, M.D. Robert Buckman, M.D., Ph.D.

The University of Texas MD Anderson Cancer Center Program on Interpersonal Communication And Relationship Enhancement (I*CARE)

Please go to www.mdanderson.org/icare to view “On Being An Oncologist.” If you are applying for CME credit, please enter through the “Earn Free CME Credit Online” link.

On Being An Oncologist - MEMV 1107 This program can be viewed at our Web site: http://www.mdanderson.org/icare or by purchasing the DVD. Continuing Medical Education (CME) Information: To obtain 3.00 AMA PRA Category 1 Creditstm, you must complete and submit the registration, post test and evaluation found on pages 48-55. Accreditation/Credit Designation The University of Texas MD Anderson Cancer Center is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The University of Texas MD Anderson Cancer Center designates this enduring material for a maximum of 3.00 AMA PRA Category 1 Creditstm. Physicians should claim only credit commensurate with the extent of their participation in the activity. This enduring material has been designated by The University of Texas MD Anderson Cancer Center for 3.00 AMA PRA Category 1 Creditstm in medical ethics and/or professional responsibility. Release Date: May 1, 2011 Expiration Date: May 1, 2012 NOTE: The content of this educational activity is reviewed annually. After May, 2012, please call the Department of CME/Conference Management at The University of Texas MD Anderson Cancer Center (713) 792-5357 for verification of the status of continuing medical education credit for this program. Target Audience This enduring material will be of value to oncologists, nurses, PAs, trainees (fellows, interns, residents) and other health care professionals. Goals • To create positive changes in physician competence in relation to communicating with patients; • To promote and foster discussions about a variety of topics related to the demands oncology places on those in clinical practice, especially personal burdens • To improve the mental health status of oncology professionals in regard to dealing with emotions and burnout by learning coping mechanisms • Professional growth Educational Objectives After participating in this enduring material, the participant should be able to: • Identify daily dilemmas and stressors involved in oncology clinical practice that may negatively effect doctor/patient communication (knowledge) • More openly discuss feelings of frustration, inadequacy and burnout without feeling ashamed, thereby making these feelings/ stressors less noxious (knowledge) • Develop new and different coping strategies, new insights and new personal resources (knowledge and competence) • Distinguish that these feelings/emotions are normal and, through acceptance of this, be able to move from the realm of being stressful to the promotion of professional growth (knowledge and competence) © 2002, 2011 2nd edition, The University of Texas MD Anderson Cancer Center. All rights reserved. No part of this work can be reproduced, distributed or otherwise used without the express permission from The University of Texas MD Anderson Cancer Center. All statements and opinions contained herein are solely those of the individual speakers and may not reflect those of The University of Texas MD Anderson Cancer Center. The University of Texas MD Anderson Cancer Center Disclosure Policy for Program Chair(s), Planning Committee Members, Teachers, or Authors and CME Activity Reviewers The Accreditation Council for Continuing Medical Education has announced standards and guidelines to insure that individuals participating in CME activities are aware of program chair(s), planning committee member, faculty/teacher/author, CME activity reviewer relationships with commercial interests that could potentially affect the information presented. The University of Texas MD Anderson Cancer Center has implemented a process whereby everyone who is in a position to control the content of an educational activity must disclose all relevant financial relationships with any commercial interest. The University of Texas MD Anderson Cancer Center has resolved all conflicts of interest prior to this activity. For information on this process, please contact the Department of CME/Conference Management at 713-792-5357.

Faculty/Program Planning Committee Members/CME Activity Reviewers/Approvers Disclosure of Relevant Financial Relationships Faculty/Program Planning Committee members and CME activity reviewers/approvers that have indicated no financial interests, arrangements or affiliations. Faculty have indicated no financial interests, arrangements or affiliations and presentations will not discuss investigational or off-label uses of a product: Walter F Baile, M.D. Robert Buckman, M.D., Ph.D. Emil J Freireich, M.D. Rhonda Prescott Kirby Cathy Kirkwood, M.P.H. Gregg Staerkel, M.D. Stephen P. Tomasovic, Ph.D. Faculty/Program Planning Committee Members/CME Activity Reviewers/Approvers Disclosure of Relevant Financial Responsibility that have financial interests, arrangements or affiliations: Christopher G. Wood, MD Grant or research support: Pfizer, Agenus; Paid consultant: Pfizer, Argos; Speaker’s Bureau: Pfizer, Argos; Honoraria: Pfizer To obtain AMA PRA Category 1 Credittm for this activity, complete the Registration Form, Evaluation, and Post-Test and send or fax to: Department of CME/Conference Management, Unit 1381 The University of Texas MD Anderson Cancer Center P.O. Box 301439 Houston, TX 77230-1439 Fax: 713-794-4734 For questions about this program, please contact: Cathy Kirkwood, M.P.H., Project Director Department of Faculty Development Interpersonal Communication And Relationship Enhancement (I*CARE) Program The University of Texas MD Anderson Cancer Center P.O. Box 301402, Unit 1426 Houston, TX 77230-1402 Email: icare@mdanderson.org Hardware/Software requirements • Windows: Intel Pentium II 450 MHz or faster, 128 MB of RAM • Macintosh: PowerPC G3 500 MHz or faster, 128 MB of RAM Computer Operating System: • Microsoft Windows XP or Vista • Macintosh OS X 10.4 or later Browser: • Internet Explorer 6 or later • FireFox 1.x or later (Windows), 1.5.0.3 or later (Macintosh) • Safari 2.x or later Flash player: • Adobe Flash Player 10.0 or later Privacy Statement: Our site’s registration form requires users to give us contact information (such as their name and e-mail address), unique identifiers (such as employee number) and demographic information (like zip code). These are requirements of the Department of CME/CM to maintain accurate records of CME accumulation. The subscriber’s contact information is used to contact the subscriber when necessary.

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Table of Contents

Background & Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 1 The Personal Demands of Clinical Oncology . . . . . . . . . . . . . . 3 Time Pressures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Communication: Seeing the Person through the Patient . . . . 11 Breaking Bad News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 The Angry Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Hope & Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Sympathy, Empathy & Personal Boundaries . . . . . . . . . . . . . 27 The Dying Patient & the Physician . . . . . . . . . . . . . . . . . . . . 31 How to Cope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 In Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Appendix I: S-P-I-K-E-S Communication Protocol . . . . . . . . 39 Annotated Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Continuing Medical Education . . . . . . . . . . . . . . . . . . . . . . . 48 CME Registration & Answer Sheet . . . . . . . . . . . . . . . . . . . . 49 CME Post Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51-52 CME Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53-55

We gratefully acknowledge

The oncologists who participated in our focus groups Megan Cole and William Hurt for their gracious gift of time and talent

Special thanks to

Robert C. Bast, M.D. Vice President, Translational Research Diane C. Bodurka, M.D. Professor, Gynecologic Oncology Stephen C. Stuyck, M.P.H. Vice President, Public Affairs Jo Ann Ward, M.P.H. Associate Vice President, Public Affairs Stephen P. Tomasovic, Ph.D. Senior Vice President, Academic Affairs Robin Sandefur, Ph.D. Past Executive Coordinator of Faculty Development & Resources Janis Apted, M.L.S. Associate Vice President, Faculty Development John Mendelsohn, M.D., President, The University of Texas MD Anderson Cancer Center and Anne Mendelsohn for their vision and support.

Project Coordinators

Sunni Hosemann, B.S.N. Program Education Coordinator, Academic Affairs Telehealth Services 1st Edition Cathy Kirkwood, M.P.H. Project Director Faculty Development 2nd Edition

Video Production

Greg West, Director of Production UT Television

Book Production

Beth Notzon Program Manager, Division Publications Radiation Oncology and Julia M. Starr Former Scientific Editor Department of Scientific Publications Eli Gukich Book Design Communications Office Printing by UT Printing & Media Services

Project Directors

Walter F. Baile, M.D. Professor, Behavioral Science Director, Interpersonal Communication And Relationship Enhancement (I*CARE) Department of Faculty Development Robert Buckman, M.D., Ph.D. Medical Oncologist, Professor, Department of Medicine, University of Toronto\Princess Margaret Hospital, Adjunct Professor Department of Behavioral Science

MD Anderson Cancer Center ÂŠ 2002, 2011 2nd Edition The University of Texas MD Anderson Cancer Center

Background & Introduction The video On Being an Oncologist had its beginnings when Megan Cole, star of the play WIT, and several members of the staff at The University of Texas MD Anderson Cancer Center led a series of focus groups made up of faculty and staff to talk about what it means to be an oncologist. Group discussion focused on the personal aspects of being an oncologist—the demands, the burdens, the rewards, the emotional costs. The video comprises extracts from those discussions, dramatized by Megan Cole and William Hurt. The aim of the video and of this workbook is to promote and foster discussions about a variety of topics related to the demands that oncology places on all of us in clinical practice, in particular the personal burdens. Those of us who worked on this project—and probably you as well—have felt that the psychological needs and burdens of patients with cancer and of their family and friends place a particularly heavy load on the clinical team. Furthermore, this burden and its psychological tolls, including the feelings of frustration, inadequacy, and even burnout and the many other emotions that we all experience from time to time, have not been comfortable subjects for discussion. The problems that accompany the job of caring for people with cancer have, of course, many features in common with clinical care in other disciplines. However, they are intensified and augmented by our patients’ feelings and fears about the diagnosis and by the social and personal attitudes and anxieties related to the word “cancer.” In addition, our current social attitudes toward serious illness and the topics of death and dying are always present in the background, making the atmosphere yet more difficult. Even though some of these factors have their beginnings long before the physician and the patient meet for the first time, they may still negatively influence doctor-patient communications, making the practice of clinical oncology more difficult.

For those reasons, clinical oncologists are more likely than clinicians in other disciplines to feel distressed, frustrated, angry, saddened, and even depressed and sometimes apathetic or burnt out. At the same time, oncologists often feel that they “shouldn’t” be experiencing these feelings, and they may even feel ashamed or worried about their own emotions and emotional stability. We hope that by airing some of these issues with the video and the workbook we will encourage reflection and more open discussion of the personal aspects of oncology care. We also hope that thinking about and discussing these issues will encourage the development of new and different coping strategies and that the discussions will lead to new insights and provide new personal resources. USING THIS PROGRAM This program may be used by individuals on their own, but we also envisioned it as a teaching and mentoring tool to be used in group discussions or even workshops. A suggested format: view the videotape in segments, stopping after each Focus Group Topic for reflection and discussion, and using the topic questions provided or your own questions or reflections. Encourage group members to write or share their own experiences and discuss their thoughts and feelings. Please read the Background and Introduction section before you begin.

THE PERSONAL DEMANDS OF CLINICAL ONCOLOGY Taking care of patients with life-threatening illnesses is a stressful experience for all of us who daily face not only the medical challenges of providing effective treatments, but also the psychological burdens imposed by patients and their own emotional reactions. Responding to patients who are desperate for cure, who may be disappointed or angry about their care, or who are unable or unwilling to face the reality of a dire medical situation puts unusual demands on oncologists. Cancer care also has a significant impact on the inner life of oncologists, who must deal with their own strong emotions connected with patient care. They may have feelings of grief that can emanate from patient loss, a sense of inadequacy, and even a feeling of self-blame when they feel that there are other things that could have been done for a patient. They may also be angry at colleagues who seem to be delivering less than optimal care, they may have difficulties negotiating closeness with patients, they may be frustrated at not being able to spend enough time with patients, and they may have many other emotions. Unfortunately, these emotions, while very common among cancer practitioners, are rarely acknowledged and may often linger outside the awareness of clinicians who are not trained to examine the sources of their distress or troublesome feelings. They are often treated as the â&#x20AC;&#x153;price one paysâ&#x20AC;? for taking care of very ill patients. It is also ironic that, while physicians readily acknowledge the emotional burdens of having cancer and encourage their patients to participate in support groups and other activities to assist in coping, they often ignore the emotional burden of being a cancer physician and rarely discuss the stresses they experience.

The medical literature is beginning, however, to acknowledge the consequences of these stresses, not only on the physician’s personal life but also on patient care. What is the consequence on the physician’s family life of long hours worked in the clinic? What impact does repeated patient loss have on the morale of the doctor? How does a physician maintain a “therapeutic boundary” with patients? How does a physician cope with feelings of not having done enough to help a patient? These are all valid and legitimate questions that deserve to be explored. When they remain foci of stress for the physician, they can result in demoralization, withdrawal from the patient, a cold and detached attitude in delivering patient care, the offering of unrealistic hopes to patients, an inability to discuss end-of-life care with patients, the hiding of negative information from the patient, and ultimately depression and burnout. The series of dramatized dialogues on the video are meant to illustrate the daily dilemmas and stresses of caring for cancer patients. They are intended to create awareness and promote discussion of the feelings, frustrations, difficulties, and also the joys of being a cancer doctor. Psychiatrists and psychologists have known for many years that the acknowledgment and discussion of stresses can make them less noxious. By identifying feelings and exploring their source, clinicians can come to accept them as normal, and these emotions can move from the realm of being stressful to actually promoting professional growth.

ON BEING AN ONCOLOGIST

â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m constantly behind and constantly pressured by being behindâ&#x20AC;?

Focus Group Topic #1 TIME PRESSURES The sense of never having enough time to spend with patients is a common feeling among cancer doctors. Comments from the members of the focus group must seem familiar to you and will doubtless raise memories of similar situations and of many others. As the old saying has it, â&#x20AC;&#x153;we always seem to leave the clinic too early and to get home too late.â&#x20AC;? Outside forces such as managed care, the demands of academia, the documentation and paperwork required, and informed patients and family members with many questions can be overwhelming. Even though progress has been made in reducing the mortality of cancer, the low rate of cure of many of the solid tumors makes it easy for us to feel that we have failed or are ineffective and that perhaps we could achieve more if we worked harder or did more. Are those feelings familiar to you? Do you feel that that is a factor or a dimension of the feeling of time pressure?

Scheduling conflicts Needy patients Long hours Never enough time

Focus Group Topic #1 TIME PRESSURES Topics for Discussion How prominent is lack of time in your list of stressors? Where does it rank among the other stresses? How many times during the day are you acutely aware of time constraints? Can you recall a recent episode where you might have wanted or needed to spend more time with a patient and felt badly that you didn’t? When you are trying to do too much in too short a period of time, are you aware of feeling “overloaded?” Are you ever aware that when time pressures increase you get physical symptoms such as sweating, tachycardia, dry mouth, queasiness? When under time pressures, do you ever become irritable or annoyed at others? How proficient are you in managing your time? What factors can you identify in your own feeling of time pressure? Is the sense of time pressure worse at any particular time—at the start of the week or at the end of it; on returning from a holiday or trip out of town? Do you ever feel badly because you don’t spend enough time with patients who “really need it?” Are there situations in clinic or ward rounds that do NOT make you feel rushed or time-constrained? Is there anything you could do to make other activities more like that? What activities, such as academic activities or research, make you feel least rushed or pressured? Do you take your worries about your patients home with you? What are some ways to improve the situation? 8

Notes

“... there’s a little bit of that person’s life that kind of escaped… it humbles you”

“When I was a student I had no idea how to talk to patients about medicine”

Focus Group Topic #2 communication: SEEING THE PERSON THROUGH THE PATIENT Acknowledging the person and the personality of your patient is a major component of the doctor-patient relationship. Communication is not just another task, not just “another part of the job you have to do,” it is an essential component of the relationship between you and the patient and affects their perception of you and the effects of the treatment. Of all aspects of communication in oncology care, perhaps the most important is acknowledging the patient’s emotional state. In that way the person who is your patient becomes more visible, and that actually makes things easier, not more difficult. Communication skills may reduce your stress, facilitating both the support of the patient and the management of the medical condition. Understanding the patient’s feelings and concerns can provide a unique perspective on the patient’s motivation and decision making, as is illustrated in the scenarios. They show how an appreciation of the personal component adds insight and may help the task of providing care.

Understanding quality of life When no decision is a decision 11

Focus Group Topic #2 communication: SEEING THE PERSON THROUGH THE PATIENT Topics for Discussion How much time on average do you spend getting to know your patients individually? What percentage of your patients do you think you know well as people? Does knowing a patient well hinder or help your clinical management? Do you think that patients value your attempts to get to know them personally? Have you ever been concerned that asking personal questions of your patient would be intrusive, take up too much of your time, or feel uncomfortable? What questions could you ask that would help you know your patient better? How do your patients react to uncertainty? How do you frame information about treatment, risks, and prognosis?

Notes

“There’s no nice way to say ‘brain tumor’…” “People know when they’re being lied to…” “…they’re not going to be patronized”

Focus Group Topic #3 BREAKING BAD NEWS Giving bad news is one of the most frequent, yet stressful tasks that an oncologist must perform many thousands of times over the course of a career. While patients have a right to information about their cancer, this never makes the task any easier. For many reasons, giving bad news can evoke strong feelings in the doctor (and the patient) that can sometimes sabotage the interview or cause communication to break down, resulting in avoidance of the discussion of negative information or a poor understanding on the part of the patient. Even though many patients today are well-informed, still it can be a dilemma to determine how much information to give the patient and how to give it. Many families also now want to participate in the care of the patient with cancer, making information sharing sometimes very complicated. Strategies and plans for communicating in difficult situations can help. An example is the “S-P-I-K-E-S” protocol that is summarized in Appendix I. All of the situations described in this section of the video were clearly difficult and awkward. It’s important to realize, however, that the difficulty originated in the diagnosis itself and in the way the patient handled the information. Perhaps a key phrase here is, “There’s no nice way to say brain tumor.” Although strategies (such as S-P-I-K-E-S) will help reduce the discomfort for both the patient and physician, they cannot remove the shock altogether. It is important to realize that and not to expect too much from the use of a strategy or plan.

My mother is not to be told Patients’ rights 15

Focus Group Topic #3 BREAKING BAD NEWS Topics for Discussion How often do you give bad news to patients and families? What is the toughest aspect about giving bad news? Are there particular patients whom you find difficult to tell? Can you recall a negative experience that you had with breaking bad news from early in your career? Are there techniques that you now use that would have made that experience go better? Can you recall a recent clinical experience that you feel went as well as it could? What techniques are you now accomplished at using? Have you developed a particular strategy, plan, or method for giving bad news? What would you say your style is? Are you likely to be blunt? Do you tailor your delivery to the patient? Have there been times when the news was so difficult to give that you “candy-coated” the information? Or left out some of it? What features of the interview or patient’s reaction do you regard as indicating that you did a good job? Do you use techniques that regularly produce these reactions? Do you particularly dread the patient becoming very angry, crying, or becoming very distressed? Is it a dilemma for you when a patient says “I don’t want to know”? How do you combine fostering hope with delivering unfavorable medical information? How do you address families’ requests to withhold bad news from the patient? Do you find that family conferences help? 16

Notes

“…most people who are angry are really scared” “…what they want more than anything in the world is you, your good graces… they need you”

Focus Group Topic #4 THE ANGRY PATIENT Among the many possible reactions to bad news, anger in a patient or relative is usually one that oncologists dread most. Feelings of anger occur frequently in situations of stress, for example, when patients are frustrated about a lab result not being ready. Anger is often a surrogate for feelings of frustration, disappointment, loss of control, demoralization, and especially fear. Many people under stress do not recognize these feelings and tend to blame others for their problems or fly off the handle. Others have learned to deal with these feelings by habitually blaming, accusing, threatening, or criticizing others. In oncology, where stress is often high, anger is not uncommon, and however many times we encounter an angry patient or relative, the experience is always uncomfortable. Anger and other strong emotions can impact the caregiver by making him defensive, causing him to withdraw or eliciting anger. Dealing with emotions, including anger, requires responses that are to some extent objectiveâ&#x20AC;&#x201D;saying what you see rather than what you (at that moment) feel. Of course, dealing with feelings is perhaps one of the most psychologically demanding (and often draining) parts of doctor-patient communication often even more so when there are high hopes or expectations about the outcome, whether they are the patientâ&#x20AC;&#x2122;s hopes or your own, or both.

Whatâ&#x20AC;&#x2122;s behind the anger? The wrong moment

Focus Group Topic #4 THE ANGRY PATIENT Topics for Discussion How often do you encounter angry patients and family members? Have you ever been physically threatened? How do you react to anger in your patients? Does anger make you go on the defensive, the offensive? Do you find it easy to identify other emotions behind patient anger? How difficult would it be for you to explore beyond the anger to identify underlying emotions? Can you identify the signals of anger in yourself? Are there reliable physical signs that you can identify as advanced warnings? Are there any techniques that you are aware of that may reduce the imminent anger (for example, are you able to use an empathic response to your own feelings, such as, “This is making me very angry”)? Is patient anger ever justified? Should we ever apologize to patients (for example, after the event)? Is it appropriate to set boundaries with patients and tell them that their anger is intimidating or unacceptable? What about patients who are out of control? Are any of your colleagues particularly capable of dealing with patients’ anger? What have you seen them do?

Notes

“…not robbing people of hope without giving false promises” “… what you’re telling me cannot be—we thought we brought him to the best hospital in the world”

Focus Group Topic #5 HOPE & EXPECTATIONS Dealing with another person’s emotions is always difficult, but it is even more difficult when there are high hopes or expectations—whether the patient’s or the physician’s. Many clinicians identify the task of keeping a patient’s hope alive or its complement, tailoring communication so as not to “destroy hope,” as one of the most important challenges in communicating with patients. Keeping hope alive while being honest with patients is a frequent dilemma faced by physicians.

Unrealistic hopes False hope Despair

Focus Group Topic #5 HOPE & EXPECTATIONS Topics for Discussion What is your personal understanding of hope? What is the physician’s obligation regarding patients’ hopes? How can you determine what patients’ hopes are? How would you ask? Is there an obligation not to “destroy hope?” How do you handle the issue of hope in a newly diagnosed patient with a poor prognosis? Have you found yourself in situations where there was a serious disconnection between you and the patient regarding their understanding of the medical facts? Do you feel that patients tend to distort information in order to “maintain their hope?” Are you ever surprised at what patients come up with when you check their understanding of the medical facts? What do you think hope is for the patient? Is it always a cure? Are there other types of things to hope for? Do you view your patients’ hopes as singular and fixated, perhaps focused on cure, or multifaceted and multifactorial? Do you use techniques that can identify the elements of your patients’ hopes? What do you do when a patient’s hopes are unrealistic? How can you introduce reality without seeming cruel or apparently abandoning or crushing the patient?

Notes

“Should I never be friends with a patient?” “The thirty year old who just got married and is going to lose his rectum and may be dead in five years… it’s not easy to tell someone that”

Focus Group Topic #6 SYMPATHY, EMPATHY & PERSONAL BOUNDARIES Your own personal boundaries, including the line between sympathy and empathy, are always a challenging part of your job. Dealing with our own hopes and emotions raises the central issue of boundaries and the nature of the relationship between the professional and the patient. In the next section, we discuss the difficulty in drawing our own personal line between our professional functions and ourselves as fellow humans or even friends. Acknowledging and responding empathically to the patient’s emotions may be quite different from the feeling you yourself have about a situation. It’s helpful to be aware of the differences. An important dictum of medical ethics warns the doctor not to get too close to his or her patients for fear of disturbing the objectivity needed to provide care. However, doctors do have feelings for their patients, and these may intensify in situations where care is given over a long period of time. Some patients more than others touch us emotionally, and sometimes physicians become close friends with their patients. This may be one reward of medicine, but the situations dramatized in the video illustrate the importance of giving some thought to your feelings for your patients. However carefully one tries to define one’s personal boundaries, in many respects, achieving a rapport with a patient may result in the physician feeling a sense of loss later on. In fact, it is likely that the sense of loss cannot be eliminated in many clinical situations, particularly in oncology.

Sympathy Empathy Attachments Friendships 27

Focus Group Topic #6 SYMPATHY, EMPATHY & PERSONAL BOUNDARIES Topics for Discussion Do you find yourself liking some patients more than others? Do you create â&#x20AC;&#x153;internal barriersâ&#x20AC;? to protect yourself from getting too emotionally involved with patients? How do you do that? Can you readily identify those of your patients who have become friends? How do you evaluate the potential risks of that? Have you ever become close friends with a patient? Gone to parties at their house? Accepted gifts from them? Are there any risks to this kind of friendship? What are they? Should physicians accept trips or vacations to visit patients who, for example, live abroad? Do you feel that when patients become friends, it can compromise your judgment about their care? What do you think the patient feels? Do you ever give patients a hug or kiss? Does it make you feel uncomfortable when patients want to embrace? Where do you draw the professional boundary in these instances? What are the factors that make giving bad news to a patient who has become your friend easier or more difficult? Do you think that physicians can learn to be both emotionally attached to patients and objective about their medical care? Do you think they should? Have you ever found yourself offering unnecessary treatment to a patient because you felt pained at their plight?

Notes

“I don’t think you can train for this until you’ve been through it” “I felt terrible. And he said, ‘yeah, but you gave me four and a half years’ ”

Focus Group Topic #7 THE DYING PATIENT & THE PHYSICIAN Care of the dying often reflects the underlying physicianpatient relationship and can strain it or sometimes strengthen it. Loss is inherent in the care of the cancer patient, since only 50% of patients on average live for more than five years. Thus, the care of the dying is as important as the care of those doing well. Losing patients is never easy, and this is made more difficult when we have become close to them, when they are young and have not fulfilled life’s dreams, or when their courage and perseverance have touched us in some way. Yet, in medicine, death is often seen as the enemy, and training does little to prepare one for the sense of defeat that can occur when patients die, despite our best efforts. Even recognizing the death of a patient as inevitable may not remove the emotional impact on the physician. When you experience strong emotions—and we all do from time to time— it’s important that you acknowledge their existence.

Distancing Continual loss A good death

Focus Group Topic #7 THE DYING PATIENT & THE PHYSICIAN Topics for Discussion How much training have you had in the topic of death and dying? Can training help you prepare for handling patient loss? What about your own feelings of grief? How do you handle the death of patients? Do you ever write to families? Attend funerals? Do you use any particular techniques to deal with the death of a patient? Have there been occasions when you have contemplated your own mortality and death? Did you find yourself making plans for dealing with it? Did the planning exacerbate or ameliorate the intensity of your own emotions? What would you want from your physician in dealing with your own dying? How could he or she help you? What would you want them to offer you in terms of information? Decision making? Emotional support? Do you ever find yourself doubting or second-guessing your medical care when your patients die? Can you recall patients whose deaths have caused you particular emotional pain? Do you sometimes feel burned out by the deaths of your patients? What is that like? Do you think that there are â&#x20AC;&#x153;good deaths?â&#x20AC;? What about patients who are not prepared for dying?

Notes

“You have to have some way to deal with that, some outside interest, some kind of belief system that helps you deal with it” “…when we go on vacation, the beeper does not go with us” “…it’s one or two days before you realize that the rest of the world doesn’t always think about cancer”

Focus Group Topic #8 HOW TO COPE Coping strategies are mechanisms that help reduce the sense of stress and emotional load; they can be practical, psychological, or both. A recent study showed that over 60% of oncologists feel burned out. That is, they feel demoralized and often depressed about their profession. There are many causes of burnout—the long hours, bureaucratic hassles, the toll of taking care of so many very ill patients, the demands of families and their own feelings of helplessness at watching people die as well as the pain of families. Yet, somehow we must cope with the everyday care of patients and get up the next day and do it again. The video excerpts in this section illustrate some ways that cancer doctors get through all of this. Perhaps the concept of the “renewable resource” is a useful analogy here. If you are able, through various coping mechanisms and strategies, to replace the psychological energy and reserves that are lost in daily clinical practice, you will manage to maintain some form of equilibrium. If you cannot do that— and we all have days when we cannot—then that may produce burnout in the long term. Reflecting on and discussing this topic may be as important—perhaps even more important—than any of the other topics, because if you are burnt out, you will be unable to help your patients deal with their own burdens.

Off service Creating “safe” space Setting boundaries

Focus Group Topic #8 HOW TO COPE Topics for Discussion How does the daily stress of clinical cancer care affect you? Can you identify the features that make a day really tough? What helps you cope with the stress of everyday oncology practice? What restores your own sense of energy and enthusiasm for your job? Do you work out? Have a hobby? When your patients thank you, are clearly glad to see you, or are grateful for your help, does that reduce the stresses that you feel? Can you easily acknowledge the gratitude of patients and family members? Are there things that you wish you could avail yourself of to get through the losses and stresses? Is family support an important factor? What have you noticed about this? Do you ever find yourself â&#x20AC;&#x153;dumpingâ&#x20AC;? your stress on your family? Do you ever find yourself relying on self-destructive coping such as excessive alcohol use? How do you give yourself a break? By taking vacations? Planning regular cultural or other events? Does your hospital or office have a place such as a lounge or office where you can take a break? Do you feel that your home and work life are in balance? Do you have any colleagues to talk to about how you feel? Do you know many colleagues who seem stressed and burnt out?

Notes

IN CONCLUSION Everyone who has been involved in this project hopes that the videotape and this booklet will help crystallize some of the biggest problem areas in cancer care and that they will provide some strategies for dealing with them effectively. Nobody who goes into the practice of oncology expects it to be easy. But, as the scenarios show, sometimes the practice of oncology is more difficult than anyone could imagine. If this tape and booklet lessen that difficulty and in the process help you become a better caregiver to your patients with cancer, then this project will have fulfilled its aim.

Appendix I S-P-I-K-E-S communicaton protocol S-P-I-K-E-S is a communications protocol for difficult clinical situations, such as when it’s necessary to impart bad news. It is summarized briefly below. You will find more detail about this protocol and how to use it in the Annotated Bibliography that follows.

Setting

Before you begin, attend to the context in which the conversation will take place. This includes such things as choosing a private setting rather than a public hallway, determining who is (and isn’t) present, sitting rather than standing.

Perception Take time before beginning to determine what the person knows or suspects about the medical situation. “Tell me what you know so far about your condition…” Note any mismatch between this and the actual medical information.

Invitation Encourage the patient to let you know how much detail he/she desires. “Are you the sort of person who…” Accept the patient’s right NOT to know (but offer to answer questions later should they arise).

Knowledge Begin to impart information (in small chunks), checking reception as you go, and responding to patient’s reactions as they occur.

Exploration Explore the patient’s understanding of what’s been said, and respond to emotions. “I can see this was more serious than you suspected…” This does not require you to experience the same feelings as the patient or to agree with his/her view or assessment.

Strategy &

summary

Propose the best medical strategy, assess patient response, and agree on a plan. End the session by summarizing, and then ask whether there are important issues or questions to discuss. Offer assurances that you will answer questions that arise later. Make a clear contract for the next contact.

Notice that the protocol calls for easing both the patient and the physician into the situation by first attending to the context of the conversation, by gathering information before imparting it, by giving feedback and acknowledgment, and by providing the structure of a summary. 39

Annotated Bibliography TIME PRESSURES Baker Laurence H, O’Connell, D and Platt, FW “What Else?” Setting the Agenda for the Clinical Interview. Ann Internal Medicine 2005;143(10), 766-770. Many times patients have concerns that go unexpressed until the end of the interview when the clinician thought that he had covered the important points of the encounter. This paper is a useful article on how eliciting the patient’s agenda at the beginning of the interview can save time later on. Beckman H, Markakis K, Suchman A, Frankel R. Getting the most out of a 20-minute visit. Am J Gastroenterol 1994;89:662–4. A discussion of four core skills that can increase the efficiency of the medical encounter and enhance the feeling of co-participation in problem-solving by the physician and patient. Dugdale, DC Epstein R. and Pantilat, SZ Time and the Patient– Physician Relationship. J Gen Intern Med. 1999 January; 14(S1): S34–S40. An overview of the issue of time pressures in the physician-patient encounter and some suggestions as how to use interview skills to save time and improve important outcomes of patient care. Gunderson L. Physician burnout. Ann Intern Med 2001;135:145–8. A brief overview of the concept of burnout and approaches for physicians to combat it, including the American College of Physicians–American Society of Internal Medicine Renewal Project. Lang F, Marvel K, Sanders D, Waxman D, Beine KL, Pfaffly C, McCord E. Am Fam Physician. 2002 Apr 1;65(7):1277-9. Interviewing when family members are present. In oncology family members often accompany patients to interviews. This can create challenges but also opportunities to involve them in the support of the patient. This article briefly discusses a core set of interviewing skills for involving families in the patient’s care and more advanced skills for managing conflict and negotiating goals of care. Lee Rs, McGrath P . Dealing with Time Pressure. International J Stress Management 1995;2(2) 79-86. A study of individuals experiencing time pressure during personal encounters revealed that those who felt effective in focusing on the task at hand, 41

viewed the encounter with a person as a challenge rather than a burden and set realistic goals were more likely to feel less time pressure and more likely to show satisfaction with the meeting. Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM, Leaning MS, Snashall DC, Timothy UK. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer 1995;71:1132–3. Emotional exhaustion, depersonalization, low personal accomplishment, and psychiatric disorders among cancer clinicians were associated with feeling overloaded, treatment toxicity/errors, and deriving little satisfaction from professional status. Clinicians who felt insufficiently trained in communication and patient management skills had significantly higher levels of distress than those who felt sufficiently trained.

COMMUNICATION: SEEING THE PERSON THROUGH THE PATIENT Baile WF, Beale E. Giving bad news to cancer patients: matching process with content. J Clin Oncol 2001;19:2575–7. How a failure to understand a patient’s expectations and anxieties can lead to misunderstanding and conflict in the doctor-patient relationship. Suggestions for ways to efficiently explore patients’ expectations and concerns. Branch WT, Malik TK. Using ‘windows of opportunities’ in brief interviews to understand patients’ concerns. JAMA 1993;269:1667–8. How to pick up on verbal cues from patients during appointments to identify issues that are of concern to them and that may affect their quality of life, satisfaction with medical care, and compliance with treatment. Smith RC, Hoppe RB. The patient’s story: integrating the patient- and physician-centered approaches to patient interviewing. Ann Intern Med. 1991;115: 470–7. Techniques for eliciting the patient’s perceptions, needs, and concerns in the context of the medical interview and the advantages of this approach for patient management. Voices From the Lived World of Illness: Advanced Cancer DVD The film leads the viewer into the “in-illness” experience and highlights patient’s expectations of doctors, the impact on one’s sense of self and relationships with others, spiritual issues, dying and hope. Available at http://www.communicationinmedicine.org/

BREAKING BAD NEWS Buckman R. How to Break Bad News. A Guide for Health Care Professionals. Baltimore: Johns Hopkins University Press, 1992. A comprehensive guide and six-step protocol for telling families and patients about adverse medical information. A Request for Nondisclosure: Don’t Tell Mother Hallenbeck J and Arnold R. J. Clin. Oncol. 2007; 25: 5030-5034. What to do when family or loved ones want to withhold bad news from patients. Guten CF, Ferris FD, Emmanuel L. Ensuring competency in end-of-life care. Communication and relational skills. JAMA 2000;284:3051–57. An expansion of the Buckman six-step method for giving bad news that includes setting treatment goals, advance care planning, withholding or withdrawing therapy, making decisions about life-threatening illness, resolving conflict around futility, and discussing death and dying. Lubinsky MS. Breaking bad news: dealing with the mimics of denial. Journal of Genetic Counseling 1994;3:5–12. Differentiates “true” denial (repudiation of reality) from a number of more benign coping strategies (disbelief, deferral, and dismissal) used by patients and families when dealing with bad news.

THE ANGRY PATIENT Astrow AB. Isn’t there someone to blame? J Clin Oncology2007;26(9):1560-1561. Discusses how the oncologist can frame and survive the anger and blame that may emerge in patients around death and dying. McCord RS,Floyd NR,Lang f and young VK. Responding to anger directed at the physician. Fam Med 2002;34(5):331-336. It is suggested that apologies and explanation are likely to be most effective in simple situations such as patients’ being kept waiting. Platt FW, Gordon, GH. Anger. In: Field Guide to the Difficult Patient Interview. Philadelphia: Lippincott, Williams & Wilkins, 1999, pp 75-83. How patient anger affects the physician, and some practical management tips, including pitfalls to avoid.

HOPE & EXPECTATIONS Evans WG, Tulsky J, Back AL and Arnold RM. Communication at times of transitions: how to help patients cope with loss and re-define hope. A review of the dynamics of patient challenges as they face losses associated with phases of their illness and several strategies that may accomplish the goal of helping them to maintain hope. Fallowfield L. Truth sometimes hurts but deceit hurts more. Ann NY Acad Sci 1997;809:525–36. Discusses the implication of clinicians concealing or altering medical facts to protect the patient from “losing hope.” Argues that most patients today desire accurate information across the disease spectrum and that most patients also have mechanisms to assist them in coping with bad news. Suggests that, for most patients, health care providers will accomplish much by focusing on helping patients redefine hope in terms of realistic goals of care and maintaining quality of life. Gerretsen P and Myers J. The physician: A secure base. J Clin Oncol 2008;26(32): 5294-5296. A case discussion raises the point that patient comfort can be derived from the perception of physician availability that provides the security that comes with feeling one is not alone. Sardell AN, Tierwieler SJ. Disclosing the cancer diagnosis. Procedures that influence patient hopefulness. Cancer 1993;72:3355–65. The authors empirically examined the extent to which various forms of physician disclosure of a cancer diagnosis are seen by patients as more or less hopeful and as favorable or unfavorable.

SYMPATHY, EMPATHY & PERSONAL BOUNDARIES Banja JD. Empathy in the physician’s pain practice: benefits barriers and recommendations. Pain Medicine 2006; 7(3): 265-275. Explores the phenomenon of empathy from the perspective of the physician and proposes a communication model valuable in communicating when facing challenging emotional situations. Gabbard GO, Nadelson C. Professional boundaries in the physicianpatient relationship. JAMA 1995;273:1445–9. Discusses the limits and parameters of behavior that characterize the fiduciary relationship between physician and patient. These include sexual boundaries, gift-taking, personal disclosure, and physical contact with patients and families. Factors leading to boundary violations and ways to increase awareness of and to prevent them are outlined. 44

Meier D, Back AL, Morrison RS. The inner life of physicians and care of the ill. JAMA 2001; 286:3007–14. Examines how physicians’ emotional responses to seriously ill patients can affect the quality of care and the physician’s own sense of well-being and accomplishment. Proposes a model for increased self-awareness in identifying and working with emotions that may affect patient care. Suchman AL, Matthews DA. What makes the doctor-patient relationship therapeutic? Exploring the connexional dimension of medical care. Ann Intern Med 1988;108:125–30. Considers the essential elements of the relationship with a patient with a view toward defining the role of the physician in situations in which there is no appropriate biomedical response.

THE DYING PATIENT & THE PHYSICIAN Baider L, Wein S. Reality and fugues in physicians facing death: confrontation, coping and adaptation at the bedside. Crit Rev Oncol Hematol 2001;40:97–103. Describes common physician reactions to patients with cancer and how they can represent barriers to comprehensive patient care. Berry, S.R. Just Say Die . Journal of Clinical Oncology 2008; 26(1):157-159 Discusses when and why oncologists and other physicians avoid using the term “dying” and how reintroduced into our discussion with terminally ill patients can actually improve their care. Block SD. Psychological considerations, growth and transcendence at the end of life. The art of the possible. JAMA 2001;285:2898–2905. Illustrates using cases how enhanced understanding of the common psychological concerns of patients with serious illnesses can improve not only the clinical care of the patient but also the physician’s sense of satisfaction and meaning in caring for the dying. Mount B. Dealing with our losses. J Clin Oncol 1986;4:1127–34. Discusses the impact of the stresses of oncology practice, including frequent patient loss, the quest for cure, and professional idealism, and suggests a number of self-reflective techniques to diagnose and address professional stress.

Renz M, Koeberle D, Cerney T and Strasser F. Between utter despair and essential hope. J Clin Oncol. 2009;27(1):146-149. How a model of patient coping with severe illness called “the stages of maturation,” provides guidance for both compassionately and professionally accompanying patients at the end of life. Shanafelt T, Adjei, A and Frank L. When Your Favorite Patient Relapses: Physician Grief and Well-Being in the Practice of Oncology. J Clin Oncol. 2003;21(13):2616-2619. A reflection on how grief, disappointment and watching the suffering of others are part of caring for critically ill patients and how the importance of self-care and support are necessary in enabling us to be effective clinicians.

HOW TO COPE Creagan ET Bombarded by stress. Healthy habits to avert burnout. Minn Med 1999;82: 14–5. A practicing oncologist offers practical recommendations for dealing with the demands of clinical care. Gabbard GO. The role of compulsiveness in the normal physician. JAMA 1985;254:2926–9. A thought-provoking article discussing intrinsic factors in those deciding on a medical career that may predispose them to burnout, including difficulty in relaxing, reluctance to take vacations, chronic feelings of not doing enough, and other factors that interfere with the healthy pursuit of pleasure and sense of accomplishment. Rabow MW, McPhee SJ. Doctoring to heal. Fostering wellbeing among physicians through personal reflection. West J Med 2001;174:66–9. Describes a staff and faculty development program implemented at the University of California, San Francisco based on a monthly discussion group of topics meant to address existential and spiritual themes in the work of the physician. Discusses ground rules, topics considered, and feedback from physicians participating in the experience. Shanafelt T, Chung H, White H, Lyckholm LJ. Shaping your career to maximize personal satisfaction in the practice of oncology. J Clin Oncol. 2006 Aug 20;24(24):4020-6. How oncologists can avoid burnout and increase the likelihood of achieving personal and professional satisfaction by optimizing career fit, identifying and managing stressors specific to practice type, and achieving the optimal personal work-life balance.

Weiner E, Swain, GR, Wolf B, Gottlieb M. A qualitative study of physicians’ own wellness promotion practices. West J Med 2001;174:19– 23. Assessed the specific practices used by 130 physicians to promote wellness. These sorted themselves into five main categories. The ability to balance several of these techniques in dealing with life’s stressors appeared to correlate with improved levels of psychological functioning.

Continuing Medical Education On Being an Oncologist

2nd Edition

The content of this educational activity is reviewed annually. After May, 2011, please call the Department of CME/Conference Management, at The University of Texas MD Anderson Cancer Center (713-792-5357) for verification of the status of continuing medical education credit. To obtain credit, you must complete and submit the post test answer sheet and evaluation and obtain a score of at least 70%.

Target Audience, Purpose, Educational Objectives The primary intended audience for this Continuing Medical Education material is physicians who work with cancer patients, however other healthcare professionals caring for patients should also find this program relevant to them and their clinical practices. The program was designed to â&#x20AC;&#x153;give a voiceâ&#x20AC;? to the often unspoken, unexplored issues and concerns that arise out of the practice of oncology, perhaps impacting the personal life and well-being of the oncologist. Its purpose is to increase awareness and promote discussion of such issues. Use of the materials as suggested will enable the practitioner to recognize some of the stressors inherent in cancer care and their potential consequences and identify strategies that may be helpful in alleviating stress and enhancing relationships with patients.

CME Registration and Answer Sheet The University of Texas MD Anderson Cancer Center On Being An Oncologist PROGRAM CODE: 1107 INSTRUCTIONS for AMA PRA Category 1 Creditstm Special Prerequisites For Participants: None To participate in this continuing medical education activity: • View the video at www.mdanderson.org/icare, click on Earn Free CME Credit and scroll to the On Being An Oncologist Video • Use the pages from the workbook or print the documents from the Web site • Record your responses to the Post-test (scoring at least 70% of questions correct), and Mail or fax registration, answer sheet and evaluation pages to: Department of CME/Conference Management, Unit 1381 The University of Texas MD Anderson Cancer Center P.O. Box 301439 Houston, TX 77230-1439 Fax: (713) 794-4734

POST TEST: Circle best answer: 1. 2. 3. 4. 5.

A B C D E A B C D E A B C D E A B C D E A B C D E

6. 7. 8. 9. 10.

ABCDE ABCDE ABCDE ABCDE ABCDE

PERSONAL INFORMATION- Please print Name______________________ Highest Degree (MD, PhD, etc.)______________ Specialty____________________________________________________________ Institution___________________________________________________________ Mailing address_______________________________________________________ City, State, Zip _______________________________________________________ Phone ______________________________Email ___________________________ The University of Texas MD Anderson employee? Yes or No If so, include employee ID#_________ I am claiming ______ AMA PRA Category 1 Credits™ for this activity, all of which are ethics/professional responsibility credits (Maximum 3.00) Signature______________________________________________________ NOTE: To receive credit, you must return this form and the Evaluation Form found on pages 53-55.

CME POST-Test Questions The University of Texas MD Anderson Cancer Center On Being An Oncologist PROGRAM CODE: 1107

1. Which of the following factors is mentioned in this program as a stressor specific to the practice of oncology? A. The psychological burdens that patients bring to the situation related to their diagnosis B. The ever-present threat of death and dying C. The effect of lack of sleep on the doctor D. The pressures of managing time E All except C 2. According to this program, which of the following are potential negative effects on patient care of ignoring such stressors? A. Unrealistic hopes B. Demoralization C. Emotional withdrawal from patients, resulting in cold or detached delivery of care D. Inability to discuss end-of-life issues with patients and families E. All of the above are mentioned 3. What are some of the strategies for offsetting such stressors that are specifically mentioned in this program? A. Talking with colleagues, role models or mentors B. Shopping C. Taking time off D. Acknowledging and discussing stressors E. All except B 4. In the section on Time Pressures the discussion is about all of the following except: A. Not seeing the patient for a period of time that seems long enough B. Being constantly behind at work C. Missing events with family because of work D. How to manage your time appropriately 5. Which of the following items are discussed in the section on â&#x20AC;&#x153;Breaking Bad News?â&#x20AC;? A. Differences in giving bad news to a patient you have known for a long time and having to give bad news to someone you have just met B. Suffering is not just physical pain, but a threat to the integrity of the human being C. Obligations and truth telling D. All of the above 51

6. When discussing angry patients, Megan Cole states that she came to realize that: A. It is always best to call a patient advocate when the patient is angry B. Most people who are angry are really scared C. It is a really good idea to call in the legal department right from the start D. All of the above 7. Which of the following describes how William Hurt stated he dealt with angry patients? A. He leaves the room and counts to 10 slowly before beginning the discussion B He asks the patient to take a deep breath and count to 10 before beginning the discussion C. He acknowledges that the anger is appropriate, but not helpful D All of the above 8. In the section on Sympathy, Empathy and Personal Boundaries which of the following is not discussed? A. Demands of being a caregiver at home and at work B. Emotional involvement with patients C. How to break bad news to the family in a compassionate manner D Studies stating that Medical Students interact better with patients, interns worse, residents worse and fellows worst of all. 9. In the section on the Dying Patient & The Physician, Megan Cole describes all of the following except A. The reality that patients die creates emotional tension that is always there B. The concept of a good death C. Agitated family members who want a lung transplant for the patient D. How to resolve conflict with the patient and family members 10. In the section of â&#x20AC;&#x153;How to Copeâ&#x20AC;? which of the following suggestions are mentioned? A. The need for a lounge and exercise room B. Realizing that if you are struggling hard, it is because it is hard C. No pager when on vacation and having someone who tells you they know itâ&#x20AC;&#x2122;s hard D. All of the above

CME EVALUATION NOTE: For credit you must fax both sides of this document and return with the registration/ answer sheet form. Test questions do not need to be faxed. Program Name: On Being An Oncologist Date: ____________________________ Program Code: 1107 1. I am a:  Physician  Non physician, please specify _________________________________________________ 2. The program content helped me achieve the following objectives categorized as knowledge (principles learned), competence (ability to apply knowledge), and/or performance (skills, abilities and strategies implemented in practice) and/or patient outcomes (changes/improvements in patient care/ patient health status). Strongly Agree

Agree

Undecided

Disagree

Strongly Disagree

Objective A: Identify daily dilemmas and stressors involved in oncology clinical practice that may negatively effect doctor/ patient communication (knowledge) Objective B - More openly discuss feelings of frustration, inadequacy and burnout without feeling ashamed, thereby making these feelings/stressors less noxious (knowledge) Objective C - Develop new and different coping strategies, new insights and new personal resources (knowledge and competence) Objective D – Distinguish that these feelings/emotions are normal and, through acceptance of this, be able to move from the realm of being stressful to the promotion of professional growth (knowledge, competence)

0-25%

26-50%

51-75%

76-100%

Knowledge

Competence

Performance

Patient Outcomes

What percentage of the objectives were met? What percentage of this information was new to you?

4. Overall the information presented will enhance my practice in the following manner.

5. As a result of your participation in this activity, what will you do differently than you did before in your practice/research activities? ___________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 6. What are the barriers or other factors that may prevent you from implementing a change in practice? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 7. How will the information presented impact patient health status in your practices? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 8. What questions do you have that you are not getting answers to and/or what patient problems or patient challenges do you feel you are not able to address appropriately or to your satisfaction? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Strongly Agree

Agree

Undecided

Disagree

Strongly Disagree

In general, the overall organization and quality of the program met my expectations

Comments: __________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 10. Was any bias toward a commercial interest* noted in the information provided (products/ services unduly favored or promoted)? *A commercial interest is any entity producing, marketing, re-selling, distributing healthcare goods or services consumed by, or used on patients. The ACCME does not consider providers of clinical service directly to patients to be a commercial interest. YES

If yes, please identify product/service, faculty, and/or presentation(s) ______________________ ____________________________________________________________________________ ____________________________________________________________________________ 54

11. What changes would you recommend to make this activity a more meaningful experience? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 12. What topics would you suggest for future presentations? ____________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________