Brittany Goetzel

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Ms. Brandi Bradley
ENC 2135
02/18/16
Matters of Life and Death with Oneself in Pediatric Oncologists
There are many communities that makeup the medical field, but one of the most heartbreaking
communities, is the Pediatric Oncology community. A commonly noted issue in this community, is whether or not
the Pediatric Oncologists’ (PO) medical practices are affected after the death of a patient that they worked with.
Others outside of this community don’t actually think about this problem as a whole, because they don’t see the
doctors’ emotions eat them up, nor do they know how different the doctors performed before meeting them. This
community is very special, because it helps to cure babies, children, teens and adolescents from serious diseases or
illnesses. The primary focus in this medical field, is on cancer and hematology, which is the study of the blood. No
matter what, communication is always a key requirement for any community to function well, but of course issues
can arise whether it’s from lack of communication, or various other reasons.
In the pediatric community there are well over 1,000 doctors throughout the world. Several of those doctors
are in hospitals in the United States. The United States of America contains 3 hospital programs that are in the top
10 throughout the world for Pediatric Cancer. Those hospitals are St. Jude’s, Children’s and Aurora (Ranking Web
Hospitals). The reason these hospitals are ranked so high in the world, is because they have low mortality rates, high
cure rates, good patient-physician relationships, and a well working community as a whole (Ranking Web
Hospitals). In order for a community to work properly, it starts with its members. This community can contain many
members throughout its structure. Some of those members are the physicians or doctors, nurses, radiologists and
surgeons. All of these members have to communicate effectively with one another, in order for everything to go
smoothly throughout this field. If one part of the communication goes wrong, then major consequences can happen,
like performing wrong surgeries or giving the wrong medications to the wrong patient. Although those are worst
case scenarios, they are very detrimental to a hospitals ranking system.
Since this community relies on communication greatly, that means the communication has to be
immaculate; whether it’s with the patients, families or other colleagues. There are different ways to communicate
within this community, which is otherwise known as the genres. Some specific genres within this community for the

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issue, is talking with psychologists or other colleagues. The first genre, is talking to psychologists. Psychologists are
there to listen to what the doctors want or need to talk about. This helps the doctors to maybe cope with the death
that has occurred. Although, sometimes some doctors don’t want to talk to a trained professional and feel that they
are a failure if they do. If the doctors don’t want to talk to a professional, then there are other ways of
communication about this issue, which is with other colleagues. This genre can help, by talking to someone that has
been in the same exact place that the doctor is at right now. Hearing how other people coped, can always make
another person feel more content or know that they aren’t the only one that has been in this position before.
Although these are very good ways to communicate with others about this issue, but these communications don’t
always help with the coping of the death. With that being said, a common conception is that all doctors or soon to be
doctors have to realize, is that Pediatric oncologists will not be able to save all of their patients’ lives. Death for a
Pediatric Oncologist can truly be heartbreaking and arise problems for the doctor with their work ethic. With that
said, the issue within this community is whether or not a Pediatric Oncologists’ work ethic and medical practices
change after the death of a patient in general.
Dr. Ofri states in her Introduction of her book What Doctors Feel: How Emotions Affect the Practice of
Medicine, that emotions exert the strongest influence on medical practices (Page 1). A common misconception that
is viewed throughout the world, is that doctors are emotionless (US News and World Report Ratings). That
statement is truly false. Doctors are far from emotionless. Elizabeth Stewart, whom was interviewed, stated that she
has felt so many emotions throughout her career. Some of those emotions correspond directly with what is in the
book that Dr. Ofri wrote. Some of those common emotions, which can affect medical practices are: anger,
nervousness, jealousy, fearful, ashamed or burned out/tiredness (Ofri, 1). Students in the medical field are told from
the get go that emotions will always cloud judgement. People can make irrational decisions if they are in distressed
emotional places, but doctors have to overcome this problem somehow.
The most challenging aspect with empathy to a doctor, is when the sufferings don’t make sense; for
example, a tumor (Ofri, 15). This relates completely towards the Pediatric Oncologist community, since this field
deals with finding tumors all of the time. Finding a tumor can be distressful, especially if the tumor is incurable,
which then means the patient most definitely is going to die. When distress is settled in from a death of a patient and
there is no grieving time given, that’s when things can go wrong. “When there is no time or space to give grief its

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due, burnout, callousness, PTSD and skewed treatment decisions are at risk” (Ofri, Chap. 4). Doctors in the Pediatric
Oncology field never get the time to actually grieve, since they have so many patients to deal with every day. That’s
when medical practices can start to diminish. One affect with death that can impact the Pediatric Oncologists
medical practices, is sense of belonging. One doctor stated in the Nature and Impact of Grief Over Patient Loss on
Oncologists’ Personal and Professional Lives, that “I come in and I don’t really want to be here at all. It’s an effort
to drag myself down to the hospital.” From this study, it was found that 55% of doctors agreed to this statement.
That then shows, that at least half of the doctors say that emotional distress from their job, makes it hard for them to
go to work. If they lack the motivation that much, then they aren’t fully there during their jobs, which ultimately
concludes that their medical practices could be affected and worsen. This study was simply asking Pediatric
oncologist doctors about the death situation. With this same study, it was found that a lot of emotions came out, that
aren’t ideal in a medical situation. An example of one of those hurtful emotions, was feeling like a failure, which
then could also make it hard to come to work.
Another study that was conducted, called ‘Memorable Patient Deaths’: Reactions of Hospital Doctors and
their Need for Support. In this study it was only about patients that were memorable to them, and it talked about how
the patients affected more than one person in the hospital most of the time. If more than one person was affected by
the patient after the death, then a lot of horrible things could come with that. For example, the doctors answered
highly on being overly sensitive, an increase in dependence on others, and withdrawn or slowed thinking. In this
kind of environment, having those kind of characteristics could be a life or death situation. This just shows that their
practice has most likely changed from being on top of their practices, to now being a weak link in the hospital
setting. No family nor patient would want to see their Pediatric Oncologist like this, because then it is hard to trust
them to be able to cure another patient.
Now Pediatric Oncologists don’t deal with death just when they become a doctor, they also experience it
during their fellowship or internships. This is the time for when doctors can really figure out if this career pathway is
for them. In the study Challenges Faced by Pediatric Fellows When Patients Die during Their Training, it talks
about all of the challenges that these interns face. Some of those challenges dealt with structure, themselves and
their relationships. An example of structural challenges, was with ward duty. A ward duty, is like being on call
throughout the whole training, which means that the intern has to come in no matter what time in the day it is.

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During this training, the interns are surrounded by death because they are the ones pronouncing time of death
(TOD). Another emotional challenge with ward duty, is that relationships could be strongly developed because they
would care for the patients that others didn’t really care for. The second challenge, was with themselves. Some
examples of these challenges, were feeling vulnerable and inexperienced since at this point in their career they really
don’t know anything. Also, the interns felt alone, since they felt like they needed to be strong and not talk about any
patient losses. These feelings can eat anyone alive and make them not want to come back anymore either. The last
challenge that was touched on in this study, was dealing with relationships. Some examples of these challenges were
with patients/families because during the rotations they never knew how much time they would have with that
patient whether if it would be days, weeks, months or years. Another challenge in relationships, was with their
superiors, since the superiors never helped with ways to have them cope with the deaths.
A very common theme that explains why medical practices would be affected after a death is emotions.
Although, there could be possibly some other reasons for why medical practices could change after the death of a
young patient, besides just emotions. One of those other reasons, was stated in the research study called Exploring
Moral Distress in Pediatric Oncology; A Sample of Registered Practitioners. In this study it mostly touches base on
patients that share several doctors and nurses. During this study, it was found that once the patient dies or is about to
die, then the communication lacks greatly, which then gets in the way with work. Sometimes the doctors didn’t even
want to work together anymore because of what happened previously. Then after there was a lack of communication
noticed within the team, then the physicians or nurses in the pediatric oncology community would withdraw
themselves from difficult situations. All of these facts above greatly show for why emotions can really affect the
medical practices of pediatric oncologist doctors after the death of a patient.
Although there is another side to this issue that was found. This argumentative side stated that there is no
difference in the medical practices of pediatric oncologists after the death of the patient for several different reasons.
For this side of the argument it was also stated, that the amount of time knowing the patients didn’t matter at all,
because a good pediatric oncologist should be able to overcome any kind of death they face and not allow it to get in
the way with their career. The three main arguments for no medical practice change after death were: the doctor
thinking positively, noticing that they tried their hardest or having previous experience.

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The first argument that is brought up, is that the doctors will think positively. This helps a doctor so much.
One of the common positive thoughts that is stated in the study Doctors’ Emotional Reactions to Recent Death of a
Patient, is that the patient is in a better place. Yes, this might sound horrible, but when dealing with cancer patients
there can be severe pain incorporated. Another reason that the doctor’s think like this, is because for a kid to go
through all of the chemotherapy and radiation can really harm their little bodies. Doctors believe that putting the
young kids through these medical practices more, is just unethical if it isn’t working. One doctor stated in this
article, “If you saw some of the kids’ reactions after treatments or from the pain you would then understand the
reasoning behind this, it was heartbreaking because you couldn’t do anything to get rid of it even if you tried your
hardest.” No one can understand this, unless it is experience first handedly.
A second argument that is brought up, is that the Pediatric Oncologists have tried every single medical
practice of cure, but sometimes it just isn’t enough. This argument was stated in the study called General
Practitioners’ Beliefs and Attitudes about how to Respond to Death. What the anonymous pediatric oncologist
doctor meant, is that sometimes the physician will try every medically known way to try and cure the patient, but
some types of cancers just can’t be cured. It might be hard on the doctor at the time, but the physician doesn’t want
to put the young patient in any more harm than good. The last and final argument for noticing no change in medical
practices after the loss of a patient also came from this same research study. The argument, was that experience
helps to make the loss a little easier. When a person first starts out in this specific community, everything will hurt so
much, because the future doctors aren’t used to this kind of grieving process. Although as time goes on, the grieving
process does become easier, because the doctors are more experienced and understand what helps them to get
through the loss of a patient, so they don’t have their emotions get in the way with work. As time goes on people
gain more knowledge in this career field, and understand that sometimes it just happens and it isn’t the pediatric
oncologists’ fault. Overtime people will notice this too, but it will hurt at the moment in time.
No matter what side of this issue a person is on, there will always be the need to cope with the situation.
Some of those coping strategies, are bereavement debriefing sessions and examples of personal ways to help cope. If
a person copes, then the chances of the Pediatric Oncologists’ medical practices being affected after the death are
slim. Although if a doctor does not deal with each loss, then previous losses can be intertwined with their recent loss
and just make the doctor a complete mess (Keene, 185). The first coping strategy, is bereavement debriefing

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sessions. A bereavement debriefing session, is specifically aimed at providing emotional support and increasing
one’s ability to manage grief (Keene, 185). In order for a bereavement session to work properly, the session has to
occur within the week or next couple weeks after the death of the patient. In the bereavement debriefing session, the
physician gets to answer questions related to that specific patient death that is causing distress and is with a
bereavement coordinator. Only some hospitals have this as an offering to their staff; for example, John Hopkins is
one of those hospitals. During this study the Pediatric Oncologists that took part in it resulted with 98.4% found
these sessions helpful, 97.8% thought they were informative and 97.8% also found them meaningful (Keene, 187).
Based off of these results the bereavement sessions tend to have high turnover rates from emotional distress of the
patient deaths.
There are then several ways to cope for a pediatric oncologist, which is all given in two different articles.
One of the articles, Oncologists’ Protocol and Coping Strategies in Dealing with Patient Loss, states that seeking out
social support and attending activity-oriented coping techniques were the top two ways the doctors got better
(Granek, 941). Some given examples for social support, were talking to spouses or family members, friends or other
health care professionals. Although, the best social support, is one that can relate to what the doctor is going through
at the time. Granek also states on page 944 to be careful for what colleagues the doctor talks to, because not
everyone will agree with certain medical practices. Another main coping strategy, was attending activity-oriented
techniques, which consists of the doctor doing their hobbies, conducting research, taking time off or exercising
(Granek, 941). One doctor stated that engaging in activities that don’t involve thinking about the patient or
remembering anything about the patient, gives an ease of mind (Granek, 946). The next article that gives different
coping strategies, was Dealing with Stress, Burnout, and Grief in the Practice of Oncology. This article states that
some common coping strategies, are to sleep, laugh, and make a change or share responsibility with other doctors
(Lyckholm, 754). What Lyckholm meant for making a change, is by joining in groups that will help. For example,
doing clinical research for maybe the specific cancer that killed the patient (Lyckholm, 754). Dr. Stewart also
believed in these coping practices by relying on others too, but there was one very interesting one. Elizabeth Stewart
also liked to rely on her dog as support, because she would always show love and affection to her; yet also let her
get a breath of fresh air on their walks.

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As one can see, this career field can be pretty heartbreaking, and wonder how these people can even stay in
this career field. Elizabeth Stewart is a Pediatric Oncologist who primarily focuses on treating children with solid
tumors. Solid tumors are considered high risk tumors that can spread throughout the body or relapse in a patient
making it harder to treat (Stewart). Dr. Stewart has been awarded several great achievements in the Pediatric
Oncology world. Some of those awards, were the Phoenix Children’s Hospital Intern of the Year, Tri Delta Woman
of Achievement Award and St. Jude Children’s Research Hospital Employee Spotlight (Stewart). All of these awards
she won for a great reason, because she is a determined woman in this community. Her interview was heartwarming
for why she became a doctor after she was award the Tri Delta Woman of Achievement Award. Personally one can
see that these doctors have the personal drive, and that is what helps make them stay in this community. Not only
that, but as Stewart said in her interview, “Of course there are good days and bad days, but the good days far
outnumber the bad ones.” As the doctors go through their career the best way to be able to stay strong, is by focusing
on those numerous good days. Some of examples, are when former patients get married, go to medical school or
graduate (Stewart). These good times help to know that the doctor is what helped put them where they are today, and
that is what pushes a doctor to still pursue this type of a career.
This issue is very important to be notice, because many doctors are dealing with the stress of their job,
which is causing them to burnout. Even if some people don’t believe that the pediatric oncologists’ practices have
changed from the death of a patient, they still experience burnout. The more doctors that experience burnout because
of the job, the less there will be. If we start losing all of these amazing Pediatric Oncologists, then more children will
die from cancer. Kids should have the right to live, because they never chose to live with cancer, it sometimes just
happens. Having specific doctors helping out in the world for kids with cancer is the greatest thing to have to help
decrease childhood mortality rates in all countries. Babies, kids, teenagers and adolescents all deserve to get a
second chance at a normal life, and that’s exactly what these doctors do.

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Works Cited
"‘Memorable Patient Deaths’: Reactions of Hospital Doctors and their Need for Support." Medical education 41.10
(10): 942; 942,946; 946. Print.

Granek, Leeat, et al. "Challenges Faced by Pediatric Oncology Fellows when Patients Die during their
Training." Journal of Oncology Practice 11.2 (2015): e182-9. Print.

Granek, Leeat, et al. "Oncologists’ Protocol and Coping Strategies in Dealing with Patient Loss." Death
studies 37.10 (2013): 937,952 16p. Print.

Granek L, Tozer R, Mazzotta P, Ramjaun A, Krzyzanowska M. Nature and Impact of Grief Over Patient Loss on
Oncologists' Personal and Professional Lives. Arch Intern Med.2012;172(12):964-966.

Keene, Elizabeth A., et al. "Bereavement Debriefing Sessions: An Intervention to Support Health Care Professionals
in Managing their Grief After the Death of a Patient." Pediatric nursing 36.4 (2010): 185,9; quiz 190. Print.

Lyckholm, Laurie. "Dealing with Stress, Burnout, and Grief in the Practice of Oncology." The Lancet Oncology 2.12
(2001): 750-5. Print.

Ofri, Danielle (MD). What Doctors Feel: How Emotions Affect the Practice of Medicine., 2014. Print.

Pye, Kate. "Exploring Moral Distress in Pediatric Oncology; a Sample of Registered Practitioners." Issues in
comprehensive pediatric nursing 36.4 (2013): 248-61. Print.

Redinbaugh, Ellen M., et al. "Doctors' Emotional Reactions to Recent Death of A Patient: Cross Sectional Study of
Hospital Doctors." BMJ: British Medical Journal 327.7408 (2003): 185-9. Print.

Saunderson, Eric M., and Leone Ridsdale. "General Practitioners' Beliefs and Attitudes about how to Respond to
Death and Bereavement: Qualitative Study." BMJ: British Medical Journal 319.7205 (1999): 293-6. Print.

Stewart, Elizabeth, Dr. "Interview for Pediatric Oncologist Community." E-mail interview. Mar. 2016.