Under Pressure and Coping
Thanks to the vision of one man, health-care workers now have an
emotional outlet to help them deal with the stress and loss that
they face on a daily basis.
. illustration by Alex
Nabaum.
Krishna Komanduri, MD, first met the young man about a
decade ago while completing his
cancer training in San Francisco.
The man was in his early 30s, about the same age as Dr. Komanduri,
and had been healthy - a runner, in fact - before developing a type
of cancer called Hodgkin's disease.
"He's really one of those patients who has stayed with me the
longest," says Dr. Komanduri, a stem-cell transplant physician now
working at the University of Texas M.D. Anderson Cancer Center in
Houston. Sitting in an auditorium among other M.D. Anderson
clinicians, Dr. Komanduri describes how he had recommended a
typical regimen of chemotherapy, to be followed by a series of
radiation treatments.
The young man did start the chemotherapy. But from the beginning,
he resisted the idea of
radiation, worried about the potential for
long-term damage, including to his heart. Dr. Komanduri tried to
dissuade him - repeatedly. Without the radiation, the risk of
recurrence was significantly greater, he told the patient. But he
couldn't make any headway. "I went as far as I could," he says to
his M.D. Anderson colleagues, "without alienating him or pushing
him away."
Finally, he says, he had to learn to live with - both
professionally and personally - the consequences of the patient's
decision.
Dr. Komanduri's story unfolds during a powerful hour in which
doctors, nurses, and other M.D. Anderson staffers break from their
usual focus on blood-cell counts and chemotherapy side effects to
discuss the emotional underpinning of decisions they make every
day. The sessions, called Schwartz Center Rounds, are held on a
regular basis at hospitals around the country - the result of a
vision of
Boston health-care attorney Kenneth Schwartz.
During his 10-month battle with cancer in the mid-1990s, Schwartz
wrote an account for the
Boston Globe
Magazine - an article that's still circulated among
clinicians - detailing his fight for survival and the significance
of seemingly small acts of compassion along the way. Several days
before his death, Schwartz amended his will to launch the center
that today bears his name.
The idea behind the rounds, developed by the staff at Massachusetts
General Hospital Cancer Center and the Kenneth B. Schwartz Center,
was to create a safe place for hospital staffers to express the
frustrations, fears, and sadness that can reverberate during the
drive home. Virtually no subject is off-limits - coping with angry
patients, treating sick colleagues, the role of spirituality, and
delivering bad news, among others, are all valid. Underlying many
conversations is one common thread, a psychological tightrope that
clinicians frequently walk: how best to provide compassionate care
and really connect with patients without becoming vulnerable to a
personal burnout.
"Unfortunately, it had been looked at in the past as a
vulnerability and a weakness to show emotion when caring for
patients," explains Jon Du Bois, MD, a physician leader for
Schwartz Center Rounds at Emerson Hospital in Concord,
Massachusetts. "I think it's finally time to say that the human
side of caregivers can be as important as their medical judgment
and their medical knowledge. I think the real art as a caregiver is
to blend both."
SMALL ACTS
Kenneth Schwartz's
lung cancer diagnosis was a shock; he was a
nonsmoker. Once he became ill, he never returned to work at his
high-powered law firm, focusing his energy on treatment and time
with family and friends instead.
He easily connected with people - at least 1,000 attended his
funeral - and his journey through the health-care system was no
different, says his wife, Ellen Cohen. She recalls how her husband
became acutely aware of the power of human interaction as he
underwent tests and procedures. "He realized that someone looking
at him wrong or taking time to pat his shoulder - those things
meant a lot," she says. "They could make or break his day."
Schwartz's plans to create a center were unknown, even to his
closest family, until he asked attorneys to gather in his hospital
room. Despite having difficulty breathing, Schwartz made his vision
clear, expressing his desire to launch an initiative focused on the
patient-caregiver relationship, Cohen says.
For years, the rounds were largely a Northeast effort, piloted
first in 1997 at
Massachusetts General Hospital Cancer Center in
Boston, where the Schwartz Center is still located. But the concept
continues to gain traction. By this fall, 100 health-care
facilities in 25 states were hosting the rounds, involving some
25,000 clinicians annually, nearly all of whom work in hospitals.
M.D. Anderson, which joined in early 2005, was the first site west
of the
Mississippi, according to Schwartz Center officials.
Beyond employee assistance programs and conversations in the
hallway, few outlets for reflection are available to most hospital
clinicians, says Tom Lynch, MD, chief of oncology at Massachusetts
General Hospital Cancer Center and a physician who treated
Schwartz. In today's fast-paced environment, even pausing for lunch
in the doctor's lounge is usually infeasible - if such a lounge
exists at all, says Dr. Lynch, also vice chair of the Schwartz
Center board. "We don't have a place to put the emotional and
cultural and other nonclinical parts of our interactions with
patients," he says.
Through the years, the Schwartz topics addressed behind closed
doors have been as disparate as the hospitals involved. One session
at Massachusetts General focused on the stresses that spouses and
other family members face when hospital clinicians bring their jobs
home with them. At the University of Rochester Medical Center, a
patient with terminal cancer was asked to attend. "He talked about
what it was like to know you are dying," says the New York
facility's physician leader, Timothy Quill, MD. "Then he talked
about what he was most hoping for and what he was most afraid of."
M.D. Anderson physicians say they wanted to assist their
doctors-in-training (called fellows or residents) to better hone
their communication skills. But experienced physicians quickly
learned that they could benefit as well. "I think it has personally
helped me to be more honest with myself about [the hard side of]
what I do," says Michael Fisch, MD, an oncologist at the Houston
cancer center and one of the physicians who help lead the
rounds.
BEHIND CLOSED DOORS
During this particular M.D. Anderson round, the conversation
begins, as all of the one-hour sessions do, with a brief recap of a
patient case that has touched some chord or sparked a larger
discussion within the hospital. Confidentiality is protected, as
patient names are never used during rounds.
The doctor leading the session, James Cox, MD, chief of the
radiation oncology division, describes the case of a 50-something
woman who traveled from another state several years earlier to
pursue aggressive treatment for lung cancer. But the combination of
chemotherapy and radiation took a toll. Dr. Cox explains that,
despite the woman's commitment to continuing treatment, some of the
technicians involved worried that her body badly needed a
break.
From there, the group of more than 50 hospital clinicians embarks
on a wide-ranging conversation. First, they discuss the challenges
of treating a fellow clinician; the woman was a nurse. Then they
talk about the stress involved when not everyone on the medical
team agrees on the best course of treatment. They wonder if a
patient might admit concerns to a social worker or a radiology
technician - concerns that might never be voiced to a
physician.
Dr. Fisch then asks if any clinician has encountered the opposite
scenario: a patient refusing a clearly beneficial treatment. That's
when Dr. Komanduri weighs in, speaking from the back of the room.
He had developed a good rapport with the patient in question, which
was in part what made the refusal so puzzling, he tells the group.
And the man had a highly treatable form of cancer.
Dr. Komanduri pauses at times as he speaks. "Our relationship
really had to evolve," he recalls, "from one where I felt like he
was making the wrong decision to one where I had to live with the
decision he had made without saying, 'I told you so.'?"
The man relapsed about two years later, and the Hodgkin's disease
returned. He didn't survive. Did they ever, asks Dr. Fisch, discuss
the radiation decision? "It was the elephant in the room," Dr.
Komanduri answers. "I felt like any mention would have been
devastating to him."
Plus, he points out, it will never be known if the radiation would
have made a lifesaving difference.
MEASURING RESULTS
The Schwartz Center Rounds, held monthly or every other month, are
limited to an hour and are usually over a meal. Participants gather
in an auditorium, a conference room, or another comfortable
setting. Schwartz officials ask a physician at the hospital to
spearhead the effort. The nonprofit center pays for the food and
gives a small stipend to the facilitator leading the sessions. They
also provide initial training and ongoing input.
They advise clinicians to avoid, at least at first, topics that are
too controversial or too gut-wrenching, including very recent
patient deaths.
It's better for participants to become comfortable with the
emotional and open-ended nature of the discussions, says Marjorie
Stanzler, director of programs for the Schwartz Center. "There
isn't a way to fix these issues," she says. "There isn't any right
or wrong."
This year, the center hired an outside firm to assess whether the
rounds influence patient treatment. Initial results won't be
available until 2007, but based on informal feedback, there are
numerous benefits: Hospital staffers feel less isolated; they
develop a new appreciation of the work done by colleagues - after
all, the chief of
surgery could be sitting next to a radiology
technician; and they can walk away with fresh insights.
The rounds also strive to break from the traditional hierarchy of
hospitals, with physicians in a dominant role. Sally Mack, a social
worker and facilitator at Massachusetts General, says the
hospital's clergy proved to be instrumental during one of her
rounds, in which a doctor described a patient who believed that her
survival rested entirely in God's hands. "And she wanted the doctor
to pray with her," Mack says. "And that was so hard for him,
because he doesn't pray. And he doesn't believe in God."
THE EMOTIONAL TIGHTROPE
Clinicians frequently say it's the patients whose lives mirror
their own who often resonate the most. "What's hardest for me is
when I have patients with young children," says
Bob Wolff, MD, a
specialist in pancreatic, colon, and other gastrointestinal
malignancies and who initiated the rounds at M.D. Anderson with his
colleague Dr. Fisch.
Given M.D. Anderson’s role as a referral center, with patients often traveling long distances, Dr. Wolff says that he doesn’t always have the luxury of sufficient time for mourning. “For every patient that you lose, there are two or three others who are saying, ‘You need to help me right now.’?”
Dr. Fisch, when asked to reflect on the influence of Schwartz, talks about the spiel he typically gives at cocktail parties about his medical work, much of which involves end-of-life conversations.
“I say, ‘It’s not as depressing as you think. We learn a lot. We are inspired by people’s courage.’ And that’s not false. But that’s not the whole story.
“There’s a lot of loss and grief that people experience, and I experience that with them. If you are not measuring the toxicity on yourself, how do you begin to manage it?”