Caring for Patients, Caring for Ourselves: The Role of Boundaries in Oncology

Oncology is a profession that demands not only medical expertise but also unwavering dedication and compassion. Oncologists are the guiding lights for patients on their challenging journey through cancer treatment. While the desire to provide the best possible care is paramount, it’s equally crucial for oncologists to establish and maintain personal boundaries. Failing to do so can lead to negative outcomes, not just for the clinicians themselves but also for the patients they serve.

Earlier this year, Moffitt Cancer Center’s medical oncologist Dr. Monica Chatwal co-authored a publication and chaired an ASCO education session on the "Fear of Saying No (FOSNO)" among oncologists. They explore the high-stakes challenges of oncology, modern boundary considerations within the patient-physician relationship, and actionable ways to put boundaries and other burnout solutions into place to improve physician well-being and patient care. Below, we summarize their findings and other data on the subject and highlight how Moffitt works diligently to support its oncology teams and referring providers.

The Challenges of Oncology Practice

Being an oncology practitioner is an inherently complex and intense career field. The unique challenges faced by oncology teams can result in compromised boundaries, burnout, and moral distress for clinicians.

The most prevalent and impactful challenges of oncology practice include:

• The nature of the field - The everyday existence of the oncology field includes volatility, uncertainty, complexity, and ambiguity (VUCA), placing a tremendous cognitive and emotional burden on oncology clinicians and impacting their overall well-being.
• Continuous exposure to life-threatening illness - Cancer patients may be in a state of medical or psychological crisis throughout their entire cancer trajectory. Being exposed daily to such high stakes, as well as potentially limited treatment options and possible treatment failure, make oncology clinicians especially vulnerable to burnout and psychological distress.
• Increased patient communication - The severity of side effects and increased anxiety among cancer patients has led to more communication with providers. Technology has played a role in this, with developments such as telehealth and mobile patient portals making providers more accessible than ever. Though beneficial in many ways, it challenges clinicians on how much personal contact information they should provide their patients and how available they should be to adequately care for patients while maintaining healthy boundaries.
• Complex health systems - Health systems on all levels can be challenging to navigate and inefficient.
• Increased caseloads, staff turnover, wearing many hats - With staff turnover leading to smaller care teams, increased caseloads, and organizational pressure to see more patients with less time dedicated to each, oncology providers may face growing responsibilities and feel expected to wear many hats.

The combination of these challenges can lead to burnout and moral distress among oncology clinicians. In a study, 45% of oncologists reported experiencing emotional exhaustion or burnout-related depersonalization. This can lead to fatigue, cardiovascular issues, cognitive dysfunction, and behavioral distress and jeopardize the clinicians’ well-being, detracting from the care they can provide their patients. This may also unfortunately lead to increased physician turnover.

Notably, it can also lead to a blurring of boundaries between the clinician and the patient, making work-life balance more difficult and bleeding into compassion fatigue.

Boundaries

Generally, a boundary is a psychological distinction designed to protect or set realistic expectations of a group or individual. In medicine, boundaries protect the patient as well as the physician and the integrity of their medical relationship. In oncology, boundaries are critical to maintaining physician well-being, ensuring the best patient care, and optimizing outcomes.

We rely on social norms in many aspects of life and often don’t consider the potential benefit of setting ground rules. But ground rules in the form of boundaries create a sense of predictability and security, which is invaluable for cancer patients. For clinicians, boundaries safeguard their emotional and physical well-being, allowing them to stay engaged in their work and provide their patients with the highest level of care.

Modern Ethical Considerations

Today’s medical landscape brings up several unique boundary considerations. First, technology has eliminated physical location and time boundaries as barriers to care. While this has expanded access and positively impacted populations who otherwise found it difficult to access care, it also begs the question of just how available clinicians should be to maintain balance. When after-hours messages roll in, what’s the best practice? Should it be handled immediately? Can it wait until tomorrow? Should it be forwarded to someone who’s on call?

Another consideration is how far beyond their scope physicians should accept tasks. They are increasingly taking on tasks such as collecting records, transporting patients to different hospital wings, etc. Is this the most effective use of physician time and energy? While going above and beyond the standard call of duty may seem admirable, it can quickly turn into burnout, taking away from patient care.

Advocating for the patient is always the oncologist’s top priority, but it must be balanced with advocating for oneself – asking for help when it’s needed, delegating tasks beyond your specialty of care, and reinforcing boundaries when necessary. COVID underscored the importance of these boundaries as clinicians found it increasingly difficult not to bring the emotional weight of work home.  Oncologists have an ethical obligation to the patient to make sure not only that they have continuity of care but can also transfer care to another provider if there are issues with boundaries.

Putting Boundaries into Practice

Ethically navigating the creation of these boundaries is a delicate balance. Empathy and transparency are essential qualities in an oncology clinician, but boundaries are vital to provide the stability, structure, and emotional safety cancer patients require during their journey. For oncologists, boundaries can help dissolve inherent FOSNO – a fear that saying no could lead to the perception of avoided obligation or the potential guilt of not being agreeable.

Boundaries are not one-size-fits-all and will vary from person to person and depending on the context of the situation and the stage of one’s career. Dr. Chatwal likened physician boundaries to the guardrails at museums to protect physician knowledge, expertise, and ability to continue to care for patients.

Setting personal boundaries isn’t a one-time event, either. It’s a process refined over time through feedback. Here are a few of the keys to setting reasonable, effective boundaries as an oncologist:

• Be intentional with intentions. Ensure actions align with intentions to reinforce trust. Understand that sometimes, saying no can be the better option to avoid disappointment.
• Use the rule of 10s. Ask whether something will remain top-of-mind in 10 minutes, 10 hours, 10 days, weeks, months, or years. Use this perspective to determine the emotional and cognitive bandwidth something should take.
• Have everything, just not all at once. Priorities will ebb and flow along with life. Remember that it’s a marathon, not a sprint.
• Choose mentors. Beyond clinical or research mentors, seek out mentors in work/life balance and boundaries.
• Find greater meaning. Find purpose outside work through family, friends, hobbies, and interests.

Solutions should be employed on both personal and organizational levels. Mindfulness and communication training, education around burnout symptoms, resources to reduce administrative burden, keeping roles in place, meditating and deep breathing, and connecting with others can all have a positive impact.

The Ripple Effect on Patient Care 

Establishing and reinforcing better boundaries is a form of physician self-care, which translates into better patient care. While some physicians believe that creating these boundaries and showing vulnerability to the realities of life and work will negatively impact their patient relationships, it normalizes these feelings and can strengthen the relationship. Showing that kind of self-awareness and self-care encourages patients to do the same and even enhances patient care and satisfaction.

Moffitt strives to create a healthy and supportive environment for our physicians, staff, referring providers, and patients. Moffitt’s patient outcomes are up to four times the national average, and that’s due in part to our engaged multidisciplinary teams and tumor boards collaborating, placing less pressure on a single doctor and relying on various departments’ specialty expertise to create the best possible care plans.

We’re also a leader in technology and research, which helps our teams work smarter, not harder, taking advantage of in-house research, clinical trials, and innovative treatment technologies.

Finally, Moffitt lives out the pillars of outreach, education, and support for our patients and referring providers, keeping everyone on board throughout the cancer journey. Streamlined patient care through our clinical pathways ensures each patient gets the safest and most effective treatment options possible, and patient education helps them identify the best resources for them. We also collaborate closely with referring providers through our physician relations team for any additional support that may be needed.

To refer a patient to Moffitt’s specialized oncology programs, complete the online form and get a response within one business day. Once a referral becomes a Moffitt patient, you’ll get access to a secure portal to view the clinical components of your patient’s medical records at any time.