Lecture
5.1. Features of the physician's interaction with the oncology patient
In recent times, medicine has seen a growing interest in various aspects of the problem of the patient's own attitude toward treatment and their adherence to treatment (compliance), which affect both the effectiveness of treatment and the patient's quality of life [2, 11]. The need to take the patient's treatment adherence into account is especially acute in oncology, since new, high-tech methods of diagnosing and treating oncology patients focus the physician's attention on the treatment being administered, and the physician feels responsible only for its outcome. At the same time, the psychological side of the disease – the personality of the patient, their experiences and emotional state, which influence treatment – is not taken into account by the physician to a sufficient degree [12]. In the course of treatment, the physician directly enters into psychological interaction with the patient. In oncological disease, this interaction – even more than in any other – is significant for the patient's treatment and their adaptation to the disease. The physician turns out to be precisely the person who can most competently and most adequately help the patient exist in the situation of illness. The very life of the patient largely depends on the physician's words and actions. According to a study conducted in the USA aimed at identifying the socio-psychological needs of oncology patients, the services available to them, and the evidence base for their intervention, it was established that the most effective measures were those to improve communication between physician and patient, and only then – psychotherapeutic and
psychological counseling, while the use of psychopharmacological agents ranked third.
Thus, the oncologist is required to engage in psychologically competent professional interaction with the patient. The absence of professional training in communicative activity, which is an integral part of any physician's work, creates a number of difficulties in relationships with oncology patients.
The oncology patient wants the physician's psychological involvement in their personal situation: they want the physician to understand their experiences and to sympathize with them, to strive to help specifically them in treatment. At the same time, this is precisely what constitutes an enormous problem for the physician, since the «physician-patient» relationship is asymmetrical. If the patient's position is unique, often critical, then for the physician the relationship with this patient is one of many relationships with patients whom the physician must simultaneously interact with in the course of treatment. The difficulty for the physician lies in the need to create individual relationships with each patient, yet in doing so the physician must proceed not from their own personal preferences and assessments, but be guided by the fulfillment of the goal of their professional activity. Such relationships affect not only the emotional state of the patient, but also the physician themselves, contributing to their emotional burnout.
Also, the absence of professional psychological training leads to the physician, in interactions with the patient, often being guided by their own life experience, which is frequently unprofessional and may increase emotional tension in the physician's relationship with the patient. In a study conducted among physicians of various departments of the N.N. Petrov Research Institute of Oncology and trainees of the oncology department of the I.I. Mechnikov North-Western State Medical University, participants were asked to complete a statement in free form: «a patient one wants to communicate with…» and «a patient one does not want to communicate with…». Using content
analysis based on the characteristics of the chosen definition, all the physicians' answers were divided into several groups: the patient's attitude toward treatment, the patient's attitude toward the physician, features of the patient's personality, the patient's psychological state, the patient's intellectual and cultural level. Thus it was found that in the conditional situation of «favorable» psychological interaction («a patient one wants to communicate with…»), 36.9% of the definition variants proposed by physicians belonged to the group «patients' attitude toward treatment» (for example, «wishes to recover», «is set on being cured», «adequately understands the situation of the disease»). In other words, physicians chose a professional stance for interacting with the patient. Personal qualities (for example, open, approachable, sociable, friendly, trusting) were chosen by 17.5% of physicians in defining a patient they would want to communicate with. At the same time, when physicians defined patients they would not want to communicate with, the largest number of physicians – 35.9% – chose definitions characterizing the patient's personality (for example, cloying, quarrelsome, tiresome, hypochondriac, egotist, smug). Only 8.7% of physicians chose definitions of patients they would not want to communicate with that characterize the patient's attitude toward treatment (for example, «lack of faith in being cured», «negativism toward treatment», «demands untruth about the disease»).
Thus, in the conditionally «unfavorable» situation of psychological interaction with the patient, the physician shifts from a professional stance into the sphere of personal relationships; that is, while engaging in professional activity, the physician uses not professional communicative skills and abilities, but the habitual skills of communicating with people that they employ in their everyday life.
The shift from a professional stance into the sphere of personal relationships increases emotional tension in the physician's interaction with the oncology patient, and a basis for conflict appears.
The resolution of these problems lies in the physician's awareness of their professional stance and in their striving for conscious relationships with the patient.
At the foundation of effective interaction between the physician and the oncology patient – which influences the patient's mental and physical well-being and determines their attitude toward the disease and treatment – lie several factors, the main of which are the following:
Understanding the experiences and mental state of the oncology patient. In interacting with the oncology patient, the oncologist needs to understand and take into account the situation of oncological disease. When a person is diagnosed with cancer, the «illusion of immortality» is destroyed, a real threat to life arises, and the fear of death is the core of the oncology patient's experiences. In connection with this, a destruction of the habitual picture of the world occurs in them – a picture that contains the person's ideas and beliefs about themselves and the surrounding world, formed over the course of life and consciously, but more often unconsciously, answering the need to live in a world that is safe for them. In other words, information about oncological disease destroys the patient's safe existence. In this state, they feel a loss of control over the situation, the disease, the treatment, and life as a whole, in the face of an uncertain future. From the standpoint of clinical psychology, the situation of oncological disease can be characterized not simply as stressful, but as an extreme or crisis situation, for which extremely intense, ultimate experiences are characteristic. It is precisely the extremity of the oncology patient's experiences that creates a threat of psychological traumatization, one of the manifestations of which is post-traumatic stress disorder (PTSD), observed in approximately one-fifth of all oncology patients. The clinical picture of PTSD in oncology patients includes such signs as: 1) intrusive recurrent dreams about events connected with the disease; any pain or other
physical sensations incomprehensible to the patient evoke neurotic and psychosomatic symptoms in them, which for the patient symbolize a recurrence of the disease, the appearance of metastases; 2) the patient cannot talk about their disease, an encounter with the specialists who treated them provokes tears; the patient expresses a desire to «forget everything», while tending to isolate themselves from other people and seeing no life prospects; 3) difficulties falling asleep, irritability and outbursts of anger; difficulties concentrating attention, a heightened level of vigilance.
The manifestation of empathy (sympathy and compassion, a non-judgmental attitude). The situation of oncological disease is filled with the patient's agonizing and extremely intense experiences, which require enormous inner work to resolve the existential and other psychological problems that have arisen or become pressing in connection with the disease. In their professional activity, the oncologist has to interact not with an ordinary patient, but with a deeply suffering one who needs emotional support, which becomes possible in the presence of the physician's empathy, one of the physician's principal communicative qualities (appendix 2). Empathy can be defined as the ability to «put oneself in another person's place». In contrast to sympathy and antipathy, which are evaluative judgments in relation to another person (like – dislike), empathy is a non-evaluative judgment: the physician sees and understands the patient's emotions and reactions in the situation of the disease, but does not judge whether they are good or bad, whether they like them or not. Empathy allows the physician not only to better understand the sick person, their thoughts, feelings, and desires, but also to show the patient that the physician understands and sympathizes with them. Empathy allows the physician to see and understand not only the outwardly manifested behavior of the patient, but also their inner state, which is not overtly displayed. It can be expressed at both the verbal and the nonverbal levels [10].
Adequate informing about the disease (diagnosis, examinations,
treatment, procedures, complications, further life under the conditions of the disease).
The most important aspect of the physician's interaction with the oncology patient is informing the patient, especially in those cases where the patient truly wants to have information about the disease (appendix 3). The availability of sufficient information helps the patient in forming an adequate attitude toward the disease. Scanty information about the disease (for example, when the patient is told only the diagnosis), avoidance of questions concerning treatment and the patient's condition, increase the patient's anxiety, give rise to fears, and may create or intensify the symptoms of the disease. According to our data, practically all patients acknowledge the leading role of the physician in treatment – and this is precisely a sign that the patients themselves do not control the situation of the disease and treatment. The physician, by providing the patient with adequate information not only about the diagnosis but also by discussing the treatment plan with them and informing them about the goals of the examinations and procedures being carried out, creates in the patient a sense that the patient themselves participates in treatment and thereby, to a certain degree, controls the situation. All of this contributes to the oncology patient's awareness of their motives for recovery and to the formation of their responsible attitude toward treatment and toward their life, and gives them the chance to feel their own strength and significance in resolving problems vitally important to them.
Cancer is one of the most mysterious and insidious diseases. A vast number of various kinds of myths arise around oncological diseases, which are widespread both among patients and their relatives and among the population as a whole. Mythical notions exist in the medical community as well. It has long been noted that for the patient the physician's words and the intonation with which they are spoken are of great importance: on them depend the patient's mood, their mental and, consequently, physical state, their attitude toward the disease and treatment. In connection with this, physicians often form mythical notions about their psychological influence on the oncology patient and about their professional role. We identify the following mythical notions that may be observed in the medical community [10].
Myth 1 – «The physician is the best psychotherapist for the patient, so another specialist is not needed». Not infrequently this opinion of the physician is shared by patients as well. The meaning of this myth is the not always conscious striving of the physician to satisfy their need to be significant and to raise their self-esteem.
In reality: the oncologist, the medical psychologist, and the psychotherapist, in interacting with the patient, proceed from different professional standpoints that require different approaches and methods. In providing psychological help, the oncologist, the medical psychologist, and the psychotherapist do not exclude but complement one another.
Myth 2 – Patients in whom the physician shows interest and to whom the physician devotes attention are more adherent to treatment and, possibly in connection with this, their treatment proceeds more successfully. This is explained by the patient's involvement in the treatment process: they feel themselves to be an active participant in it and a partner of the physician, which possibly also affects the results of treatment. At the same time there exists a
physician's myth that attributes the aforementioned to the physician's unique abilities; that is, the physician sees (or wants to see) in the success of the patient's treatment only the features of their own personality, manifested in their skill in influencing the patient and thereby improving their condition. Behind the myth lies the physician's unconscious need to dominate.
In reality: discussing the disease and treatment with the patient forms in them an adequate attitude toward it, and the presence of emotional contact with the physician reduces emotional tension, which may influence treatment.
Myth 3 – The oncology patient's strong negative feelings and experiences draw the physician in to the point of the sensation that the physician has «caught» the patient's feelings. The notion that one can «catch» another's feelings is a myth. Behind this lies the physician's emotional exhaustion, vulnerability, and lack of awareness of their own feelings in the process of interacting with the patient.
In reality: in the absence of professional communicative skills in the physician (appendix 2), they are unable to be aware of and
separate their own feelings from the patient's feelings; they identify with the patient and the sensation arises that they have «caught» them. In this case a blending of the physician's personal and professional stances takes place.
The mythical notions indicated are conditioned by the notions existing in the medical community about the personal qualities inherent in the physician. The comprehension of the personal qualities connected with the physician's profession takes place throughout the specialist's entire professional life, beginning from the moment of entering medical school. As research shows, students studying at medical school have an idealized notion of the medical profession, which is corrected in the course of training. At the same time, the idealized image of the physician is endowed with all positive qualities to the maximum, which is hardly possible in real professional life.
The idealized image of the physician, in contrast to the idealized notion of the medical profession, may persist not only during study at university, but also frequently after its completion. This infantile personal stance of the student, and then of the physician, based on the illusion of omnipotence, may be one of the sources of constant disappointment and dissatisfaction in work, which contributes to the physician's emotional burnout.
For effective interaction with the patient, the physician needs to know the features of their own personality (for example, high anxiety, pedantry as a consequence of rigidity, slowness, hot temper, etc.), which in themselves are neither bad nor good, but which, manifesting in certain situations, may create difficulties and limitations in communication. In addition, the physician, like any person, may have their own unresolved personal and professional problems; moreover, not all of them can even be resolved, owing to various circumstances. The presence of these problems may also manifest itself and affect interaction with the patient, so it is important for the physician to be aware of their unresolved problems.
According to research, future physicians, especially first-year students, consider the motive of helping people to be an important condition of a physician's successful activity. At the same time, the physician's professional competence is often imagined by them as an unconditional accompaniment, following from the desire to help people given a stable job in a prestigious place. If, going forward, professional competence does not become the principal orientation in the physician's profession, leading to constant self-development and self-improvement in the profession, then this may lead to the development of a professional crisis.
A physician's professional activity can only be carried out in the process of communication with the patient. Physicians' low professional competence in the sphere of effective communication with patients leads to their failure to understand the patient's emotional state. Thus, research
shows that in the notions of both students and physicians there dominates the image of a preferred patient who is not suffering and going through hardship, but an optimistically disposed person – which does not correspond to reality, since the real patient is always a suffering sick person [10]. The absence of professional psychological training conditions the presence of the physician's difficulties and conflicts with patients and their relatives, which causes disappointment in the chosen profession and in itself may lead to emotional burnout and a professional crisis.
The problem of emotional burnout in medical workers is one of the important and complex problems in medicine, since it concerns the mental and physical health of specialists called upon to treat other people. Moreover, it becomes not the personal problem of the physician or nurse, but acquires a public resonance. The professional activity of physicians and nurses is accompanied by heightened workloads caused by the specific nature of their labor, by high emotional and moral tension, which contributes to the emergence and development of the emotional burnout syndrome. The absence of psychological training of physicians and nurses for interacting with patients aggravates the problem of emotional burnout. At present, the task of forming in the physician and nurse a psychological competence – which is the foundation of their readiness to be aware of the meaning of their work and their professional stance – stands acutely.
The problem of emotional burnout stands especially acutely among oncologists and nurses of the oncology clinic, since by
the nature of their professional activity they constantly communicate with the gravely ill, who are in a critical state not only from a medical but also from a psychological point of view and, as a consequence, experience extremely intense negative emotions. At the same time, oncologists and nurses, facing daily the negative emotional experiences of patients and their relatives, are themselves involuntarily drawn into those experiences. Constant emotional tension and the inability to cope with professional stress create a number of serious problems in the medical personnel of oncology institutions: a feeling of emotional fatigue and emptiness appears, a cynical attitude toward work, and callousness in relation to patients. This circumstance cannot but be reflected in the well-being (physical and psychological) of oncologists and nurses, reduces the effectiveness of their interaction with patients, and contributes to the formation of the emotional burnout syndrome.
The aim of the study was to examine the features of the emotional burnout syndrome in physicians and nurses working in an oncology institution.
147 physicians of various departments of the N.N. Petrov Research Institute of Oncology and trainees of the oncology department of the I.I. Mechnikov North-Western State Medical University took part in the study. Of these, 48.3% (71 people) were men, and women accounted for 51.7% (76 people). All the studied physicians were divided by age into three groups: group 1 – up to 40 years (29.4%), group 2 – from 41 to 60 years (51%), and group 3 – from 61 years and older (19.6%). By length of service, the distribution across four groups was as follows: group 1 – up to 10 years
(31.9%), group 2 – from 11 to 20 years (27.7%), group 3 – from 21 to 30 years (17%), group 4 – from 31 years and more (23.4%).
Also studied were 48 nurses working in various departments of the N.N. Petrov Research Institute of Oncology. All the studied
nurses were women aged from 21 to 79 years, average age – 42 years. Length of service: from 1 year to 35 years, average length of service – 17 years.
The psychological study used a questionnaire developed by us, which was aimed at examining professional motivation and certain personality features of the physician and nurse, and psychological tests: the professional burnout (PB) test by N.E. Vodopyanova (based on the model of C. Maslach and S. Jackson) and the method for diagnosing the level of emotional burnout (EB) by V.V. Boyko (appendix 5).
The obtained results of the study were statistically processed using correlation analysis. Emotional burnout was assessed by the presence of significant differences between the indicators of the PB test and the questionnaire data, as well as between the EB test and the questionnaire data.
The study of PB in oncologists showed that on all three subscales – emotional exhaustion, depersonalization, and reduction of personal accomplishment – the indicators are at a medium level, which testifies to a medium level of professional burnout in oncologists. The results of the EB test showed that in the tension phase, in the group of oncologists an emerging symptom was found – the experiencing of psychologically traumatic circumstances, which manifests in an intensifying awareness of the psychologically traumatic factors of professional activity. In the resistance phase there are two emerging symptoms: an expansion of the sphere of economizing emotions occurs, which manifests outside of professional activity – at home, in communication with friends and acquaintances (at work the physician becomes so tired of contacts, conversations, and answering questions that they do not want to communicate even with close ones), and a reduction of professional duties is observed, which manifests in attempts to ease or curtail duties that require emotional expenditure. One symptom in the resistance phase has already formed – inadequate selective emotional response – and is observed in those cases
when the physician ceases to grasp the difference between two fundamentally distinct phenomena: the economical manifestation of emotions and inadequate selective emotional response. In other words, the physician inadequately «economizes» on emotions, limiting emotional output through selective response to patients; emotional contact is established not with all patients, but on the principle of «want to – do not want to» – in an inadequate or selective manner. Thus, in physicians the resistance phase is in the stage of formation, which denotes resistance to the emotional impact of work: to emotional interaction with patients.
Male oncologists and female oncologists practically do not differ in their degree of emotional burnout, which to some extent confirms the hypothesis voiced in the literature that the profession of physician requires certain qualities that level out differences by sex.
Such symptoms of emotional burnout as anxiety and depression, as well as psychosomatic and psychovegetative disturbances, manifest depending on the oncologist's age: the older the physician, the more pronounced the aforementioned symptoms of emotional burnout.
A negative correlation was revealed between length of service and reduction of professional duties, which shows that the greater the length of service, the less physicians curtail duties associated with emotional expenditure. In other words, with an increase in length of service, the physician devotes more attention to the emotional side of their activity. In groups 1 and 2 the symptom of experiencing traumatic circumstances is emerging, which manifests in an intensifying awareness of the psychologically traumatic factors of professional activity; in group 3 this symptom has already formed (p< 0.05). This circumstance testifies that with a length of service from 21 to 30 years (group 3) the awareness of psychologically traumatic factors connected with work increases. A supposition arises about a possible connection of this phenomenon with the fact that, according to
correlation analysis, physicians of group 3 devote more attention to the emotional side of work.
The dominant motives in choosing the profession of oncologist were: the desire to treat people (to help) – 44% and interest in the profession – 30.3%. The dominant value of work was: satisfaction from the chosen profession – 37.6% and the significance of the profession for others (feeling significant, needed) – 29.4%. It should be noted that financial security as a value of work was chosen by only – 7.3% of physicians. In this group the symptom of dissatisfaction with oneself is emerging, and there are significant differences from the group who chose satisfaction from the profession as the dominant value (p<0.05).
In our view, the oncologist's communication with the patient plays an enormous, even in a certain sense foundational, role in the formation and development of the emotional burnout syndrome in them. In physicians who experience difficulties in communicating with patients, the symptom of reduction of professional duties is emerging, and the depersonalization phase in them is in the stage of formation. More than half of the studied physicians (57.3%) noted that they have questions which are difficult for them to discuss with patients. As a rule, these were questions concerning death (for example, about the prognosis of the disease, about the incurability of the disease, «will I live?», «when will I die?»). In physicians who find it difficult to talk with the patient on topics concerning life expectancy and death, the symptoms of anxiety and depression and the expansion of the sphere of economizing emotions are emerging. There are significant differences from those who do not experience difficulties in communication
(p<0.05).
In studying professional stress it turned out that only 8.3% of physicians do not experience tension at work, physical fatigue is felt by 9.2% of physicians, emotional fatigue by 59.6% – and for them a medium level of emotional exhaustion is characteristic. Whereas a high level of burnout is inherent to physicians who experience both physical
and emotional fatigue. Such oncologists, according to our study, make up 22% of all those studied.
For physicians who are not satisfied with life as a whole, the emerging symptoms of dissatisfaction with oneself and depersonalization are characteristic. There are significant differences from physicians who are, on the whole, satisfied with life
(p<0.05).
It is necessary to single out the group of physicians who believe that illness is a punishment. They have a high level of burnout on the PB test on the depersonalization subscale. This group differs significantly from other groups, which have a medium level of burnout (p<0.05).
The study of emotional burnout in 48 nurses of the oncology clinic showed that the emotional burnout syndrome in various stages of its development is characteristic of them.
According to the results of the PB test, 44% of nurses showed a medium degree of emotional exhaustion, and 10% of nurses – a high level of emotional exhaustion. A medium level of depersonalization is present in 44% of nurses, while 19% have a high level. This circumstance testifies that almost one-fifth of the nurses are insensitive to the emotional state and experiences of the oncology patient; they merely formally carry out their duties. In addition, 75% of nurses show inadequate selective emotional response: they limit emotional output through selective response to patients; emotional contact is established not with all patients, but on the principle of «want to – do not want to» – in an inadequate or selective manner. Limitations of emotional output may arise not only at work but also at home, which may create problems in the nurse's personal life. At the same time, 38% of nurses have a high level of reduction of personal accomplishment, and 38% – a medium level. In other words, in the nurses of the oncology clinic the value of oneself as a specialist decreases,
feelings of incompetence and failure in one's activity arise, and the meaning of and desire to invest personal effort in work are lost. It is also characteristic of nurses that they deny the symptoms of burnout.
In studying the emotional burnout of nurses working in various departments of the oncology clinic, it should be noted that the majority of nurses in whom emotional burnout was revealed in the resistance phase – selective emotional response, limitation of emotional output, and denial of the symptoms of burnout – work in therapeutic departments (outpatient clinic, radiology department, etc.). In nurses working in surgical departments, the phases of exhaustion and depersonalization predominate. It should be noted that the symptom of dissatisfaction with oneself predominates in nurses in surgical departments.
With increasing age, an increase in the reduction of professional duties and in tension was observed in the nurses, which testifies that with increasing age the severity of burnout symptoms also grows.
With an increase in the nurse's length of service, the severity of such burnout symptoms as anxiety and depression, emotional detachment, and reduction of personal accomplishment grew.
The emergence of the nurse's emotional burnout was influenced by her desire to work in the field of medicine at the beginning of her professional career. Those who chose the profession of nurse as a result of circumstances, or at the insistence of parents, or for some other reasons, were to a greater degree susceptible to the influence of stress and to the appearance of burnout symptoms in their subsequent work than those who came into the profession of their own volition.
It was also revealed that the nurse's attitude toward her professional activity is connected with the presence of emotional
burnout in her. If work, on the whole, brings the nurse satisfaction and helping the patient does not evoke resistance in her, then her risk of burnout is lower.
According to the questionnaire data, it was found that the risk of emotional burnout is higher if the nurse is not aware of the personal difficulties connected with her work in the oncology clinic and with constant communication with the gravely ill. In nurses this may be connected with an insufficient level of awareness of their life and analysis of their own state as a whole, which contributes to the development of emotional burnout.
Thus, the conducted study allows the following conclusions to be drawn:
The emotional burnout syndrome in various stages of its development is encountered both in oncologists and in nurses working in an oncology institution, which indirectly has a negative effect on the quality of life of both patients and staff.
The most characteristic phase in the structure of the burnout syndrome in physicians and nurses of the oncology clinic is the resistance phase: in physicians it is in the stage of formation, and in 48% of nurses it is formed. The resistance phase consists in the appearance of resistance and denial of burnout symptoms, as well as in the «economizing» of emotions and the limitation of emotional output, which may arise not only at work but also at home.
Using correlation analysis, a direct relationship was revealed between the age of physicians and such symptoms of emotional burnout as anxiety and depression and psychosomatic and psychovegetative disturbances; in nurses a direct relationship was found with the tension phase and reduction of personal accomplishment.
With a length of service from 21 to 30 years, physicians show an increase in the awareness of psychologically traumatic factors caused by work, which is connected with a decrease in the reduction of professional duties.
In physicians who have difficulties in communicating with patients, symptoms of emotional burnout emerge: reduction of professional duties, anxiety and depression, expansion of the sphere of economizing emotions, and the depersonalization phase forms.
For the 22% of physicians who experience physical and emotional fatigue at work, a high level of emotional exhaustion is characteristic, testifying to a high level of emotional burnout.
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