Viewpoint: Why oncologists need to say 'no' more

Oncologists need to learn how to set boundaries in their professional lives and address their fear of saying "no" to career opportunities or patients that could increase their risk of burnout, said two speakers at the American Society of Clinical Oncology annual meeting, which took place in early June, according to a June 13 report from Medscape.

Monica Sheila Chatwal, MD, a medical oncologist at Tampa, Fla.-based Moffitt Cancer Center and Research Institute, said that like a painting in a museum, physicians should have "some level of guardrail" to protect their knowledge, expertise and ability to care for patients. Setting boundaries "provides more emotional and cognitive flexibility, and less uncertainty, in the relationships that we have with our colleagues, with our patients, with everyone around us," she said.

"More importantly, boundaries acknowledge that, as humans, we are multifaceted, multidimensional people," she said. "We have lives outside of medicine, much as we may or may not want to admit that. It's great to be devoted to what we do, but there are so many other aspects of ourselves that make us who we are, and that is wonderful."

Too few boundaries can lead to conflicts of interest, an imbalance of the patient-physician relationship and over-engagement, while too many boundaries may block connections and engagement with patients and reduce the "human element."

"It's a little bit of a Goldilocks situation: You want to find just the right balance, somewhere in the middle," Jonathan Marron, MD, a pediatric oncologist at Boston-based Dana-Farber/Boston Children's Cancer, said. When done well, boundaries "can ethically allow us to give more to, and partner more with, our patients, while supporting our well-being, sense of purpose, and job satisfaction," he said.

However, the idea of boundaries can go against the idea that being a physician is a calling, not a job.

"I don't think it matters whether you call it a job or a calling," Dr. Marron said. Even if "you are supposed to devote all of yourself to the work and not to anything else," there is still a need for setting boundaries, he argued. Saying "no" and allowing "yourself to be yourself" are important measures, especially in an era of telemedicine where patient portals allow access 24/7.

Dr. Marron described a hypothetical scenario where a patient has found their physician's email address and now sends "frequent emails, despite very clear instructions to use the on-call paging system for something that's urgent, and the electronic health record messaging system otherwise." The behavior causes a lot of stress for the physician and affects their care for other patients, as well as their home life. Dr. Marron asked the audience: Would it be ethically acceptable to stop seeing such a patient? A quick poll showed few hands were raised in favor.

Dr. Marron suggested this was because of nonabandoment, which is an obligation to not let patients go without providing adequate time for them to find an alternative clinician. In this scenario, Dr. Marron suggested the affected physician could find other physicians willing to take the patient, talk the situation through with a trusted colleague and only then "compassionately but resolutely" tell the patient they will be transferred.

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