Mary J. Chalino, Evelyn Y.T. Wong, Bradley L. Collins, and Richard T. Penson Division of Hematology Oncology, Massachusetts General Hospital, USA KEY POINTS
• In a safety conscious environment, errors can be emotionally devastating and challenge how we see ourselves.
• Respect the weight of emotional and existential trauma for others and yourself.
• Oncology is rewarding and demanding - compassion fatigue and burnout are common consequences, present in at least a third of us.
• Being connected enables us to engage.
• Emotional intelligence and vulnerability are essential to empathy.
• Self-care, social networks, spiritual practices, and a philosophical or religious framework help build resilience.
• Medical practice needs to be both thoughtful and mindful.
• Stop and think - knowing what you don't know is the key to asking for help.
Connection The business of modern medicine works against both professional commitment and personal connection. These characteristics are inherent responsibilities in the calling to care for the sick. To find joy in the service of humanity, to invest in health, and to both lose and find yourself in service, are principles under threat in our fast paced and increasingly complex healthcare system that is pressured by both time and money.
Clinical Oncology and Error Reduction, First Edition. Edited by Antonella Surbone and Michael Rowe. ©2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.
At Massachusetts General Hospital (MGH) there is a monthly forum, known as Schwartz Center Rounds, where caregivers can reflect on psychosocial issues in cancer care. This has been one of the most durable and effective ways to foster the connection between caregivers and patients and help advance compassionate healthcare. Dr. Wendy Levinson, Professor of Medicine at the University of Chicago, led one of the Rounds with a candid disclosure of her own experience of missing a diagnosis of colon cancer.  This then enabled healthcare professionals to openly discuss their own medical mistakes, the consequent emotions, and their Duplicate personal perspectives. A prominent aspect of discussion was the strong sense of guilt from personally taking responsibility for mistakes and the emotional scars that still smarted as participants vividly recalled the impact and pain that was felt at the time of the event. While there was good insight into the nature of errors, the high stakes and high expectations of oncology practice, and a ready acknowledgment that we are not perfect, there was a surprisingly strong pattern of shame, vulnerability, fear of criticism, and anxiety about tarnished reputations. Many participants made "if only" comments of regret, reflecting remorse over preventable aspects of the error; individuals also expressed a sense that when punishment is avoided we feel a stronger sense of guilt. There was a shared sense of insight and acceptance as people faced the personal consequences of errors as well as their own humanity, frailty, and emotional vulnerability. Honest disclosure and non-judgmental acceptance helped shed some light on their own "heart of darkness."  Balint groups serve a similar function.  Our experience of arranging physician awareness groups for fellows is that they improve communication, but are harder to sustain than Schwartz Rounds. 
Albert Wu MD, of Johns Hopkins memorably described a "hapless resident" at the center of a medical error as the "second victim."  We will always make mistakes. Recognizing the distress that results from errors, Dr. Wu emphasizes the importance of colleagues discussing the emotional impact of errors. These discussions can mitigate the experience of being "singled out and exposed." Wu was one of the first to call on senior clinicians to take a lead in "acknowledge[ing] the inevitability of mistakes."
Taking responsibility is part of pursuing excellence but as the sociologist Charles Bosk observed in Forgive and Remember, while embedded in surgical residence training, there is an intrinsic vulnerability in taking "personal responsibility."  The culture of medicine is evolving from ward round humiliation and self-regulation behind closed doors, to public accountability. Professionalism and perfectionism can demand a steep learning curve and be critical masters, but are essential in connecting to a long heritage of striving for outstanding standards and excellence every day.
Attachment and aversion We are attached to a myth of medical and personal invulnerability. After an injury, neuroplasticity confers lower thresholds for pain to avoid further trauma: a useful preventive
Figure 3.1 Attachment and engagement. Source: Bartholomew & Horowitz, J Pers Soc Psychol 1991; 61: 226-244. Reproduced with permission of the American Psychological Association.
defense, but one that can become dysfunctional as allodynia.  There is most definitely an emotional equivalent to what can be measured in the peripheral nervous system as hypersensitivity, with a far more complex cerebral overlay attaching cognitive weight to the emotional pain. In the immediate aftermath of an error, heightened scrutiny is part of the preventive commitment to never do that ever again. A serious error is a bitter experience, and a natural defense - to avoid the pain - is to push it away. This is known as aversion, an aspect of denial.  A wiser reaction to committing a medical error is known as non-attachment. Not passive indifference, but an acceptance of the situation as it is and a measured response in an appropriate manner that allows greater emotional steadiness in the face of hardships and a healthy commitment to being a part of a learning system. Arising from John Bowlby's Attachment Theory, there are four main styles that derive from the dual drives of self-esteem and sociability (secure; anxious-preoccupied; dismissive-avoidant; and fearful-avoidant) and inform coping strategies (see Figure 3.1). A high esteem sociable clinician is more likely to stay secure in the face of threat, while one with less well formed or developed personal and social skills risks fearful avoidance.
At the extremes, the archetype of Buddhist response to the threat of change, detaching and transcending, may risk as much as Catholic confession, self-recrimination or self-loathing.  There are a huge number of variables that influence the dynamics of how errors are perceived; the main ones are summarized in Figure 3.2.
Vulnerability and wholeheartedness Professor Brene Brown contends that for real change to occur, we have to be willing to give others permission to look inside us, to open up.  That vulnerability risks being shamed or feeling shamed. The distinction between feelings of shame and feelings of guilt may be useful in working towards real change. Guilt says,
Figure 3.2 Engagement context. The balance of open engagement, as opposed to defended denial, is culturally, socially, and personally framed, intrinsic and situational, but it has plasticity and should be informed, shared, open to scrutiny, and regularly reviewed.
"I've done something wrong," whereas shame says, "I am the mistake." Shame is psychologically more prone to lead to avoidant behavior, as the dynamics of shame include the wish to hide or disappear. Guilt may be a more productive feeling, which leads to learning, growth, and change. The process of change, however, requires that we become vulnerable. To learn from our mistakes and grow, we have to have the courage to be vulnerable. As Dr. Brown says, "we are imperfect," and this world is "wired for struggle, but we are worthy of love and belonging." She reminds us that the risk is that "we numb vulnerability" with addictions, like accolades, possessions, or conquests or food, but we can't do that selectively, or we will "numb joy and love."  Being vulnerable makes us authentic. Non-abandonment is a central obligation to patients, and should be to ourselves.  Brown proposes that "shame is the fear of disconnection" and challenges us to meet any challenge afraid: to "do it afraid." 
Shame Shame is a feeling of guilt or disgrace, worse than embarrassment due to the dishonor it brings or the immodesty it reflects. The action was morally wrong, not just socially unacceptable. We have violated the internal or external social norm that we "do no harm," and violated our perception of ourselves by failing. Self-reflection may be a uniquely human attribute, where we are exposed to one of our toughest critics: ourselves.
Shame may derive from the Proto Indo European skem-, as kem means "to cover." When we move from feeling that we made a mistake, to being the mistake, shame has us in its grip with significant repercussions. Our response may be positive (remorse), negative (self-contempt), avoidant (blaming), grandiose (narcissism), or hyper vigilant (defensive). The term sour-grapes comes from Aesop's fable about a fox who wanted grapes that were out of reach, and then disparaged the grapes when he couldn't think of a way to get them. In psychology, adapting the preference in this way is thought to ameliorate "cognitive dissonance." Cognitive dissonance reflects value judgments we make. In a classic experiment, children (n = 22 3-4-year-olds at the Harvard Preschool) were left to play, but first forbidden to play with a particular and highly desirable toy, their second favorite out of 10. Half were given mild warnings ("I will be annoyed") and half got severe warnings ("I will be very angry, and take all my toys, and never come back"). Approximately six weeks later the experiment was rerun with the other threat, and the sequence was randomized. The stronger threat made the children rank that toy more attractive and the mild threat less attractive (p<0.003), like the grapes that were not sour.  However, domains such as "disgust" have complex social conditioning. This is perhaps best explored by Jonathan Haidt's work, with a useful self-evaluation tool online (yourmorals.org) that can help illuminate the personal perspective on emotive issues that so polarize public opinion. 
A generous appreciation of diverse opinions fosters compassion in a clinician. This egalitarian attitude, and compassion for our colleagues, is perhaps harder to generate for others without a commitment to compassion for one's self, and without it clinicians are more likely to suffer from erosion of respect (see later section on respect).
I wish I'd thought of that ...
In his latest and very popular book, Thinking, Fast and Slow, Daniel Kahneman of Princeton, the 2002 winner of the Nobel Prize for economics, explains much of our bias in two cognitive "systems." System 1 is fast, and intuitive, driven by instinct and emotion; System 2 is slower and analytical, relying on deliberation and logical deduction. System 2 thinking is hard and humans prefer to not use their brain to think. We are lazy and prefer instant gratification, and "blink"-like intuitive judgments. Some experiences readily slip through our fingers, others were never in our grasp, and some are far beyond our reach. How do we account for issues beyond our recall, our perception, our mastery? Linguistics theory suggests that if we "talk" an issue over, ideally with someone, we will be more creative in scope and perspective.  James Pennebaker, PhD and his colleagues suggest that this may be more powerful still when we write exhaustively about traumatic experiences for four days in a row, reframing it for ourselves. 
The cognitive scientist, Noam Chomsky, linked language to "inductive reasoning." He creatively reinterpreted deductive reasoning that closes in on the truth, to logical progression. Essential to the probabilistic nature of the discipline is a healthy respect for the truth, and the commitment to continually consider that our conclusions may be false, and that it can only ever be "probable" that the conclusion is true.
The philosopher, David Hume, recommended "practical skepticism," what others might call common sense, to avoid the biases inherent in predictive heuristics (rules). Simplicity is still beautiful in complex systems, and Occam's razor holds that when there are competing hypotheses, the hypothesis with the fewest assumptions is likely right.
Critical thinking can be (i) Socratic: a dialectic to arrive at the truth or the reverse, the Buddhist Kalama Sutta which uses specious reasoning to identify fallacy; (ii) diagnostic: listing priority by how commonly something occurs, and, as in differential diagnosis, weighting low incident high risk aspects more highly; or (iii) cognitive: review (observation - look again), reevaluate (judgment - reappraise), recognize and reconstruct (strengths and weaknesses).
Humility and admiration To consciously choose to submit to a mentor or discipline may be one of the best ways to educate oneself. It's easy to forget that educo, the Latin origin, means to lead out. The first step to improvement is identifying weaknesses. Recruit to compensate for weaknesses and major in your strengths. However, developing character demands that we address all our frailties. Grasp the nettle and pay the price of greatness by being humble. Plato attributed the Delphic maxim "know thyself” to Socrates, with at least some sense of humility as we approach the sacred. In line with 1 Corinthians10:12 "Therefore let him who thinks he stands take heed lest he fall."
Admiration may be one of the keys to coping through the crisis of a serious error. Admire the team in which you work, make the system admirable, and remind yourself that you will look back on this time and admire the growth and wisdom and that you did your best, and are doing better.
Respect A fundamental value that is too often compromised is respect. Modern medicine can be of an overt or hidden culture of disrespect. We are too busy, too fast, interrupted by pager or cell phone, late, inefficient, and distracted by the computer. As a profession, we are relearning empathic responses to rebuild the clinician-patient relationship. Lucian Leape has recently commented on creating a culture of respect as an important part of the safety net in the new systems that protect patients. [18, 19]
Quality care requires more than rooting out disrespectful outbursts of dysfunctional behavior and entrenched passive aggressive resistance. It requires an elevation of culture, respecting patients' time, as much as their vulnerability, identifying how much they do know as well as what they don't know, and aligning with them against the problems.
One burnt out or disruptive physician can poison the atmosphere for everyone. Competitive and hierarchical systems can breed insecurity and aggressiveness, and a hidden curriculum that condones compromise to get on, or a resignation that humiliation and bullying are inevitable. The "broken window theory" holds that if we attend to all aspects of healthcare, including small but obvious irritants and near misses, the changes might be very significant. Clinicians need to lead in this endeavor.  Disrespectful behavior has to be addressed consistently and transparently by being clear and explicit. 
Promoting collegial cooperation and communication models the best of behavior, in line with the golden rule that we do unto others as we'd want done to us (Udanavarga 5:18; Leviticus 19:18; Matthew 7:12). "None of you [truly] believes until he wishes for his brother what he wishes for himself." [21, 22] Karl Popper's caveat that, "The golden rule is a good standard which is further improved by doing unto others as they want to be done by" is the appropriate standard and furthermore, with Kant's categorical imperative, we are to behave in such a way that our behavior can become the basis for universal behavioral recommendation.
Emotional intelligence (EI)
Emotional intelligence (EI) reflects the ability to identify, understand, and manipulate emotional responses. EI also reflects personality traits. It may correlate with leadership ability and performance, especially in jobs with a large emotional component.  Investing in aspects of EI, such as self-awareness, self-control, and the empathic response, can improve social skills, but also requires a commitment to evaluate motivation.
The brain is 100 trillion synapses. The limbic system is perhaps at the heart of the cognitive processing of emotion and the amygdala in particular mediates emotional context and helps process social cues and connection. The anterior insula contributes disgust, and the subgenual anterior cingulate sadness and depression. But these processes are not localized and are more complex than networks. 
Resilience After an error happens, an oncologist must continue on with their incredibly busy clinical schedule. With their health on the line, each patient is expecting to be taken care of by someone who is attentive, present, and caring. A physician who makes a mistake but is able to endure the hardship and move past it while learning from the experience is said to be resilient. Resilience is the ability to respond to a stressful situation in a positive manner such that overcoming the obstacle is achieved at minimal psychological and physical cost.  Simply put, resilience is the act of "bouncing back" after setbacks and serves as immunity to a number of mental health conditions, such as depression and anxiety. Importantly, Drs. Zwack and Schweitzer demonstrated a common pattern among 200 physicians interviewed about resilience, that those who were resilient acknowledged their limits, uncertainties, and errors. 
Many of the drivers of "good" clinicians - achievement orientation, self-control, independence - can also be vulnerabilities. When exhausted and if one's personal and professional life becomes hard to manage, an error may become overwhelming and provoke unhealthy coping strategies, such as substance abuse.  There are no data for oncologists specifically but, in general, rates of illicit drug use are lower among physicians. However, rates of prescription misuse are five times higher among physicians than the general public.  Physicians are generally healthy and getting healthier. They smoke a lot less (3% of physicians smoke, compared to 19% of the general population), drink the same, but typically live longer than other professionals.  Indeed, all-cause mortality for male doctors is half that of the general population, and better for every illness other than suicide and airplane accidents. [30, 31]
The choice of medical subspecialty may be counter-phobically driven by the fear of death  and resulting compulsivity. Although it is true that innate personality traits such as confidence and optimism can allow a person to cognitively reappraise situations and control their emotions,  resiliency is a characteristic that can be learned. [32, 33] It involves behaviors, thoughts, and actions that can be adopted by anyone. Nurturing close relationships with loved ones and using simple meditation techniques are a few easy ways to cultivate resiliency. Due to the long-term benefits for the patients and oncologist, resilience is a key to enhancing quality of care and sustainability of the workforce. Therefore it is in the self-interest of healthcare institutions to support the efforts of oncologists to enhance their capacity for resilience with the goal of reducing error and burnout.
Can resilience be taught? The answer is complex: both yes and no. Intuition and resilience are forms of intelligence that are in part innate, the Malcolm Glad-well "Blink" of complex, dynamic recalibration, but also the 10 000 hours of graft "Outliers" invested in to hone a talent. [34, 35] The traditional teaching approach is the assimilation of excellence as an apprenticeship with years of training and experience; you become an expert because you have made all the errors there are to make. A proactive and more modern view is that we can shortcut this process if we teach error prevention. We have to learn from other's mistakes.
Social networks Cancer care clinicians may rightly sense that their workplace is not necessarily an appropriate or comfortable atmosphere to openly discuss their feelings and fears after a mistake. Social support through family, friends, and other social ties play an important role in the maintenance of psychological well-being. Being married and having children may be protective against burnout, depression, and anxiety.  In addition, the perception of support can alter maladaptive behavioral responses by providing a sense of belonging, security, stability, a sense of purpose, or recognition of self-worth.  Socializing the experience is important for resiliency, and someone under stress may appropriately participate in community organizations or immerse themselves in intimate relationships. 
Recent work optimistically suggests that cooperative behaviors are more contagious than selfish ones.  This is, to a degree, even effective in tacit ways. Establishing effective systems to positively impact the culture really helps foster an excellent and enabling environment with the goal of optimal patient outcomes. 'For 25 years,' MGH there has been a book in the Medical ICU in which medical house officers can write about their thoughts, feelings, and associations stimulated by their caring for critical illness (as an adjunct to weekly self-awareness rounds -"autognosis rounds" - with Ted Stern MD - the psychiatric consultant in the MICU). Such rounds bring feelings into consciousness and prevented unconscious acting out towards staff and patients.  Although the book describes numerous incidents of overly aggressive medical care, it contains very few references to discrete medical errors.
Medical teams enable the delivery of complex, multifaceted care. While there is an obvious need for clear and constant communication, they provide an extra level of support to the clinician. They also require an extra level of accountability. A tough, but vital reality for the moral life, is working convictions out in how we participate in relationship and in community. Knowing what we ought to be cannot be divorced from what he ought to do. We are what we think, but we only see the evidence for that in how we behave. We cannot be islands, and find human fulfillment, which happens through participation with others. One has to be careful to use the wisdom of crowds  and not the madness of crowds. 
Burnout syndrome Medical errors physically and emotionally traumatize patients, but recent studies are beginning to unveil the significant distress physicians experience after the mistake.  The challenging combination of working closely with sick patients, unrealistic expectations, and unexpected outcomes can make clinicians prone to burnout. Burnout is a syndrome consisting of three main characteristics: emotional exhaustion, depersonalization, and reduced personal accomplishment.  Burnout can reflect the attrition of accumulated trauma or result from a crisis in someone previously well compensated and very caring. It is often associated with negative behavior reflected back at the source; the patients. More insidiously, self-protection may cause an oncologist to retreat to emotional detachment, and this distance impacts patient care. 
According to the results of a questionnaire designed to identify the rate of burnout among a representative group of American oncologists, 56% of physicians report experiencing burnout.  High burnout rates (10-69%) have been reported in multiple studies, with the best data falling in the 28-38% range. [44, 45] The majority of participants agreed that frustration or a sense of failure was the most prominent element of burnout. Renowned for highly valuing their self-image and credibility, physicians continuously strive to provide their patients with outstanding care. To acknowledge that an error has been made and discuss the situation openly is a challenge that directly conflicts with a physician's core values. It makes sense that one phase of burnout is a loss of self-esteem.  Furthermore, physicians often feel a heightened sense of personal responsibility for increasing the suffering of their patient. [46, 47]
A substantial amount of research shows a positive correlation between medical errors and burnout. In one cross-sectional questionnaire that surveyed approximately 8000 surgeons of the nation, almost 9 % of the participants reported a major medical error.  These same surgeons also reported higher levels of burnout, including emotional exhaustion and depersonalization. Another study carried out by the Mayo Clinic determined a bidirectional relationship between medical error and distress.  This seven-year longitudinal study investigated the relationship between burnout and medical error among internal medicine residents, concluding that personal distress and decreased empathy lead to errors and vice versa, creating a reciprocal cycle.
Compassion fatigue While burnout is formally defined by prospective research and qualitative domains, compassion fatigue has a softer definition. When caring for patients who are facing a life threatening illness, oncologists will continuously open their hearts and minds to listen to stories of pain and suffering. Caring comes with a cost, and emotions can be "catching." A physician who makes a medical error and believes that they have increased the suffering of their patient may find it extraordinarily difficult to process the inherent strong emotions.
Compassion fatigue overlaps with secondary traumatic stress (STS), which occurs when a caregiver experiences the consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by a patient.
 STS has been identified as a form of burnout that can emerge suddenly with little warning. While burnout is associated with a reduced sense of personal accomplishment and discouragement as a medical provider, compassion fatigue is a deep physical, emotional, and spiritual exhaustion associated with acute emotional pain. Freudberg, who originally described burnout in the therapists of returning Vietnam vets, felt that an important aspect was the loss of the sense of calling, or the original vision that drew people into medicine.  Physicians with burnout adapt to their exhaustion by becoming less empathetic and more personally withdrawn, but compassion-fatigued physicians continue to give themselves fully to their patients, finding it difficult to maintain a healthy balance of empathy and objectivity. They essentially work harder, continuing to give to others, running on empty until they collapse. Hale beautifully described this as "riding the tiger," unable to get off for fear of being eaten. 
An oncologist with compassion fatigue displays signs of chronic stress. Other symptoms include having work demands that regularly encroach on personal time, feeling overwhelmed and physically and emotionally exhausted, or having disturbing images from cases intrude into thoughts or dreams. 
Moral distress Moral distress comes from knowing the right thing to do, but being powerless to act. We are compromised by conflicting priorities, limited resources, have impossible demands or feel trapped.  Moral distress can be decreased, if not resolved, when positive action is taken, especially when it is taken together, sharing action with likeminded individuals in a movement for change. Frequently, clinicians offer care in situations of moral uncertainty, in which it is not clear what the best action would be. Moral integrity, the sense of wholeness in relationship to our actions, values, and beliefs may be the goal. However, such wholeness may be difficult to achieve.
Beyond ethics, there is a moral process central to caregiving.  Arthur Kleinman, Professor of Anthropology at Harvard, recently commented on caring for his wife dying of Alzheimer's, and defined moral as "a messy mix of emotions, values, and relationships that [i]s in conflict both within and without." He petitioned that we keep "caregiving" central to healthcare, even describing "moral practices" as the "laying on of hands, the expression of kindness, the enactment of decency, and the commitment to presence." 
Transparency and professionalism Too often the professions distance themselves with a language all their own, and impenetrable self-regulation. Accountability isn't just a modern nuisance. Being a learning community, transparent to the degree that others can learn key lessons as we improve, is vital for change even as it risks provoking defensive behavior. 
Religion and spirituality A common way for clinicians to manage stress is through spiritual or religious practices and, generally speaking, this has been associated with increased positive affect and mental health status.  A spiritual foundation adds meaning to life.  Generally, physicians are less religious than the general population, as reported in studies and Pew and Gallup polls.  Puchalski et al., in their consensus report, defined spirituality as "the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred." 
Spirituality is not necessarily dependent on a particular belief system, but is rather based on a personal value system. It can be a belief in a higher power or a person's relationship with nature, music, or a secular community. In contrast, religion involves a social construct with a set of beliefs, rituals, and formalized rules and responsibilities.  A number of studies have suggested a positive relationship between spiritual or religious involvement and physical health and psychological well-being.  However, it is unclear whether religious communities are different from other social groups that are notoriously hard to control for selection bias. Under psychological stress with a psychiatric component, religious coping is extremely common with 80% using spirituality as a coping mechanism.  However, religious coping may have a negative effect with a punitive perception of God that may be associated a higher risk of suicide. [62, 63]
Spiritual and religious support appears to operate through four main factors: healthy lifestyle, learned coping skills, supportive relationships, and a sense of peace that comes from forgiveness.
Individuals may be discouraged from unhealthy acts as a direct result of spiritual or religious sanctions against destructive behaviors such as heavy drinking or substance abuse.  Religious and spiritual practices may also promote positive psychological adjustment and coping strategies that help to buffer stress,  such as meditation. 
Being religious or spiritual is associated with have better coping skills, and by actively approaching each obstacle in a "collaboration" with the sacred.  A leading psychologist in the field, Dr. Kenneth Pargament, has studied religion and spiritual coping in the face of uncontrollable crises, such as 9/11 or getting HIV, and demonstrated better adjustment.  He illustrates that coping methods may include spiritual support from God or a higher power, reframing a stressful situation into a larger system of meaning as people come to terms with their limitation while struggling actively or collaboratively when things are beyond their control.
 A religious oncologist may be more likely to increase the meaning of a traumatic experience by asking questions such as, "What can I learn?" or "How can I grow stronger?" instead of asking, "Why me?"
Many of the benefits of faith communities stem from the development of strong relationships,  broader social networks, and greater perceived social and emotional support.  Religious adherence reduces social isolation and fosters a sense of connectedness. 
Accepting and giving forgiveness may be important for adjustment, reducing negative rumination, and cultivating peace of mind.  Deciding to forgive has been linked to greater perceived control over a difficult situation, and to lower psychological and physiological stress.  Katrina Scott, the Oncology Chaplain at Mass General Hospital, believes that forgiveness, whether from a religious or secular perspective, is really about forgiveness of self, and is a universal trait.
Religion as a response to the problem of suffering The problem of suffering in theological terms is originally attributed to the Greek Philosopher Epicurus, who framed the issue atheistically: if god is an all powerful (omnipotent), all knowing (omniscient), and perfect (omnibenevolent) being, then evil should not exist. Since evil is present in the world, Epicurus concluded that there cannot be a god. While evil is the result of human free will, most theologians have introduced the need for free will as a greater good, teaching that suffering is necessary for the growth of the soul. The Christian theologian Peter Kreeft cites God's own suffering and death on the cross as the supreme sacrifice to defeat the devil and give us access to heaven.  Trials force us to consider a greater good than our happiness (James 1). Tribulation challenges error, hypocrisy, and doubt and builds into us faith that has endurance and strength.  There is no other price that can be paid for character.
Karen Armstrong has perhaps most clearly articulated the view that religion has grown out of a need to make meaning out of our experience in an aversive and dangerous world, calling for compassion.  For a specific analysis of the perspective of different world religions, see Problems of Suffering in Religions of the World by the theologian John Bowker. 
Hinduism is the oldest world religion, predating recorded history with no known founder, and emphasizing individual responsibility, empowering people to see the future as theirs to shape. Buddhism rejects the idea of a divine creator, and articulates the pursuit of goodness, happiness, peace, compassion, wisdom, and enlightenment (Bodhi - literally "awakening"). Change is an inevitable and powerful rule of life, and the more it is resisted the unhappier one will be. Many have found freedom from their struggles in its teachings.
Judaism is the origin of the three major Western religious traditions for Jews, Christians, and Muslims. It is a religion of law, family, uniqueness, and persecution. Error is most often framed in the social obligation of a member of a patriarchal society with strong matriarchal expectations. Legally, error is divided into careless indifference or reckless disregard, but both trigger penalty. While the Aseret Hadibrot, the Ten Commandments, are the foundation of Judaism's moral law, the Mitzvot, the minor commands, illustrate a key element of Judaism: the ritual and the transcendent. The Mitzvot encourages the faithful to see the potential for holiness in every moment, mundane or profound. 
There are two major words for errors in Hebrew: chayt, sin, and avayrah, transgression. Both of them presume good intentions. Chayt comes from the word meaning "an arrow that missed its mark," and avayrah means to have unintentionally "gone beyond the line." In Leviticus 4-9, God explains that "sin offerings" (sacrifices) can atone for transgressions against the law, if done with the intent to improve our conduct. Evil intent removes the possibility of forgiveness, leaving only punishment.
In the Torah, justice was originally conceived in the same tit-for-tat direct equivalence of talion law also seen in Rome and Babylon, and memorialized as an "eye for eye, and a tooth for tooth" [Exodus 21:24]. This was not just retribution for injustice, but a method of establishing a transparent, egalitarian society. Miller explores the motives for the law of the talion and suggests that it is not just to punish the wrongdoer, but also to provide restitution, striving to make the victim whole with a commitment to balance and fairness.  Rabbis later enacted laws that allowed compensation to the value of an eye, and in the 5th century BC Rome had fines (Delicts) that replaced talion, a forerunner of the damages of civil cases. For premeditated wrongdoing, malice aforethought, the penalty is appropriately defined on a different scale to protect society from evil.
Job articulates one of the classic responses to the problem of pain, and powerfully reminds us that relatives (his wife urges him to "curse God and die" (Job 2:9)), friends, and philosophers cannot come close to a satisfactory explanation of our suffering. Even meeting God face-to-face provided no answers; just perspective. Job's argument that the Divine had no reason to punish him was left unanswered. We only learn that we cannot condemn God to put ourselves in the right (Job 40:8).
Rabbi Harold Kushner wrote When Bad Things Happen to Good People in 1978 after the death of his son from Progeria, and concluded, "I think of Aaron, and all that his life has taught me, and I realize how much I have lost, and how much I have gained. Yesterday seems less painful, and I am not afraid of tomorrow."  Echoing Job, Rabbi Kushner exhorts the reader to understand that the "ability to forgive and the ability to love, are the weapons God has given us to enable us to live fully, bravely, and meaningfully in this less-than-perfect world."  Kushner, like Job, moves the argument from the question of "why do bad things happen?" to accepting that we still have to live, choose, relate, and find meaning when bad things happen.
Later, after the terrorism of 9/11, Rabbi Kushner wrote a book on Psalm 23, seeking to remind us that "the dark days will not last forever." Psalm 23 hinges in verse 4 on the presence of God ("for Thou art with me") and His ability to restore our soul, even as, and perhaps especially as, we walk through the valley of the shadow of death. 
Christianity personalizes the presence of God with the coming of the Immanuel, Jesus Christ, God with us, far from an impersonal God out-of-touch with our fears and failings. Ken Mansfield, the US manager for the Beetles, relates this in the vernacular in his excellent book The Beatles, The Bible, and Bodega Bay. "It is OK to tell Him you hate this. It's not fair. You don't want it to happen. That's called prayer."  God is infinitely accessible. The concept of grace is central to Christianity: grace is what enables us to do better (common grace), and saves us if we don't do better (saving grace). In Matthew 23:24, Jesus challenges hypocrites who put their trust in external religion, accusing them of straining out gnats and swallowing camels, what Flannery O'Conner called "borrowed finery," the hubris that so often in Christianity is the real sin. 
Islam transformed the world with its inception, stimulating profound growth in the many cultures it touched. The Golden Era of great Islamic archetypes such as Ibn Razi (mathematician, physician, ethicist who criticized Galen's humors) and Ibn Sina (who corrected Galen's view of circulation), was strongly influenced by Islamic ideals. 1001inventions.com is an instructive resource to illuminate the virtuous life. The Prophet Mohammed transformed an entire way of life with his teaching against Bedouin tribalism, proclaiming that God is merciful and inspiring culture to transcend fear and greed, exploitation and repression.
Checklists: rites and rituals There is no existential checklist for coping. In The Checklist Manifesto Atul Gawande MD, quotes Samuel Gorovitz and Alasdair MacIntyre who addressed "why we fail in what we set out to do in the world."  They described "necessary fallibility" inherent in our limitation (capacity, resources) and vulnerabilities (ignorance, ineptitude (inadequate or incorrect application). Dr. Gawande beautifully says, "don't [just] let yourself be, start a conversation ... [commit to] learning and implementing. Not just faster, better. Discovery in action." Altruistic individuals, such as Gawande, have driven the "democratization of what were once elite methods" and the "democratization of participation," science has graduated to an open source movement. Although this approach is largely surgical, improving on shouting "'just do it, damn it," to strategy with pathways and checklists, the same principles can be applied to protect our equanimity, even with desk top reminders such as So what? Think again!
Self-care Due to the intensity of the nature of their work at an emotional level, oncologists should ideally practice self-care to lower their risks of burnout and compassion fatigue. Prospectively defined as the activities performed by an individual to promote and maintain well-being, self-care can further be broken down into personal and professional self-care. 
Personal self-care refers to the individual and the ways in which the physician takes better care of him or herself.  It involves giving attention to the most important aspects of a person's life such as their families, communities, and spirituality. A number of strategies to cultivate self-care have been identified, such as nurturing close relationships, practicing meditation, participating in recreational activities, and practicing healthy habits of exercising daily and eating a nutritious diet. Lowering risks of burnout is made possible by using a popular and useful guide that illustrates the areas to focus in one's life. Known as the Wellness Wheel, the tool identifies the following six types of wellness as the most important: physical, intellectual, emotional, spiritual, social, and occupational (Figure 3.3).  In addition to these strategies, a greater self-awareness, defined as a professional's ability to become the object of their attention, is thought to lead to improved patient care and compassion satisfaction.  Insight and self-awareness are the first steps to coping.
Figure 3.3 Wellness wheel.
Since oncologists work with an broad team of other physicians, nurses, social workers, chaplains, and support staff to take care of seriously ill patients, professional self-care focuses on the individual's habits to improve their well-being while taking the work environment into consideration. Strategies for promoting professional self-care involve creating a secure network of peers, participating in organizational events, and improving communication skills. 
You should seek out professional help if you experience significant symptoms most days, or feel suicidal.
Mindfulness Too often we hear ourselves complain that everything is moving too fast. Many spiritual techniques help us to slow down, or stop and consider. A recent and popular approach to managing stress is mindfulness: the quality of being fully present and attentive in the moment during everyday activities - real-time awareness.  This tool allows for more intentional control over the constant stream of thoughts and this increase in awareness has been proven to aid in resilience training.  Essentially, it is the practice of reflecting on the stream of thoughts, good or bad, that can overflow a person's mind and to question their validity. By doing so, an oncologist can control what they want to believe or act upon. And according to the NIH National Center for Complementary and Alternative Medicine, meditation can reduce anxiety and blood cortisol levels, which contribute to stress. Although it is not yet widely used, training healthcare professionals in mindfulness-based meditation and techniques to improve self-awareness may reduce burnout and improve empathy.  The courage for a clinician to remain present in the face of powerful emotions gives them leverage over them.
A study of an eight-week mindfulness-based stress reduction intervention for healthcare professionals, designed by Kabat Zinn and colleagues at the University of Massachusetts Medical center, successfully lowered job burnout and increased compassion in healthcare professionals.  Four meditation techniques, Hatha Yoga, sitting mediation, body scan, and a "mini-meditation that focuses on the breath," were used to place an emphasis on the present in an effort to diminish worrying thoughts. The study was able to demonstrate that mindfulness interventions can train an individual to break negative thought cycles that can result in stress responses. This is one example of a brief, cost-effective program that can be implemented in hospitals to support the psychological well-being of oncologists and other healthcare professionals. Religion and spirituality can help an individual cope with hardships by providing a stable social network and lending greater meaning to negative experiences.
Mozart effect Can music make us focus or find a higher engagement? Following the initial experiments of Rauscher et al.,  researchers have used Mozart's double piano sonata K448, which the Mozart authority Alfred Einstein called "one of the most profound and most mature of all Mozart's compositions." Philip Glass tested Mozart, white noise, or silence and then tested rats' ability to negotiate a maze. The Mozart group completed the maze test significantly more quickly and with fewer errors (p<0.01). 
Thankfulness and wisdom: humanities In oncology we should be able to learn from our patients about the significance of important relationships and avoid the top five regrets of the dying: (i) wishing you'd had the courage to live a life true to yourself; (ii) don't work too hard; (iii) express your feelings; (iv) stay in touch with friends; and (v) let yourself be happier.  In medicine we should be able to learn from our elders: (i) love what you do; (ii) don't worry; and (iii) look after your body. 
The famous history quote, that it repeats itself 'cos no one's listening, is a reminder that learning vicariously from others is the most effective way to avoid mistakes. Wisdom is the prudent and effective use of knowledge. Some people advance their wisdom through philosophy. Others find precious truths to live by in the humanities, nature, beauty, challenge, justice, silence, courage, patience, or trust.
A virtuous character is a priceless asset. Our personal life contributes to professional success. Disciplines engrain the practice of excellence and ensure the performance of the best and a commitment to get better. The egalitarian ethic holds that we all make a contribution, and the more so together.
Supporting oncology professionals after a medical error Institutional commitment to creating a culture that responds positively to the multiple systems issues inherent in the complex world of modern medicine is challenging.  Although there is a consensus that we should move beyond exposure and ridicule, or defense and litigation when there is an error, doing better than surgical morbidity and mortality conferences requires the commitment of individuals and organizations.  Hospitals are aware that fostering humility and humanity are in the long-term benefit of the caring professions but are slow to act, and there is no accepted standard. Some cancer centers have formal services available to debrief as part of Quality Assurance, or an Ethics Committee or General Counsel that might provide informal wise counsel. Chaplaincy may have a system such as MITSS (Medically Induced Trauma Support Services mitss.org), and psychiatric help is available through Liaison Psychiatry or EAP (Employee Assistance Programs). Occupational Health can be a very useful and confidential connection and under significant duress 12 weeks of leave under the FLMA (Family Medical Leave Act) is appropriate for someone with pre-existing illness, while an acute event may be covered by Workers Compensation or the American Disabilities Act that requires "reasonable accommodations" from employers. Peer support is often the main agency of a compassionate heart, helping hand, and listening ear, but many hospitals now have forums such as the Schwartz Rounds to share the burdens, responsibilities, and privileges of service to medicine.
Conclusion Facing our failures can both be an existential crisis and an opportunity for awareness that can transcend the experience of lost innocence. Open acceptance does not mean condoning errors, but enables guilt to be replaced by a shared commitment to aim at excellence together. Naive utopianism, brash stoicism, and insensitive hedonism can be replaced by a sober connection to reality that owns our human frailties, and puts in place plans for success. Such aspirations require that we both know ourselves and know a connection to something greater. The glimpses of grace that keep us thankful should strengthen our resolve to care deeply, and generously, and to never give up.
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