Training for Wellness in Pediatric Oncology: A Focus on Education and Hidden Curricula
Round 1
Reviewer 1 Report
This is an excellent commentary to include and highly relevant given the current rates of burnout among physicians working in oncology.
Perhaps in addition to psychosocial oncology competencies and palliative care education provided to trainees could also include education around self-monitoring and risk factor (personal, culture and team-related) that contribute to burnout, as well as strategies to mitigate against burnout to support career development and identity as a professional.
Author Response
Reviewer #1: This is an excellent commentary to include and highly relevant given the current rates of burnout among physicians working in oncology.
We thank the reviewer for highlighting the relevance of this commentary for oncology clinical practice and education.
Perhaps in addition to psychosocial oncology competencies and palliative care education provided to trainees could also include education around self-monitoring and risk factor (personal, culture and team-related) that contribute to burnout, as well as strategies to mitigate against burnout to support career development and identity as a professional.
We thank the reviewer for this suggestion, and agree that it is helpful to discuss individuals’ risk factors for burnout. We have added some comments about this, copied below. (Section 1. The weight of Pediatric Oncology, Page 2, Paragraph 1, Lines 46-55).
“Several studies have attempted to identify risk factors for burnout. Factors associated with burnout in oncologists include demographic factors such as being younger, or being single, personal factors such as having poor physical or psychological health, and workplace related-factors including having a high workload and inadequate work life-balance[5]. However, for many of these factors, it is unclear whether they are causes or consequences of burnout. Additionally, while it can be helpful to use these risk factors to identify individuals at risk of burning out, it is not always possible for individuals to address these risk factors. Perhaps as a result, research on burnout has shifted beyond individual factors to exploring the culture in which burnout occurs.”
In our original submission, we discussed some culture-related risk factors for burnout, below (Section 1. The weight of Pediatric Oncology, Page 2, Paragraph 1, Lines 53-64).
“Perhaps as a result, research on burnout has shifted beyond individual factors to exploring the culture in which burnout occurs. Ariely et al. identified key contributing factors within medical culture that may lead to burnout, including asymmetrical rewards, loss of autonomy, and cognitive scarcity[5]. They define asymmetrical rewards as an aspect of a culture that demands perfection, does not celebrate success and penalizes errors heavily. Loss of autonomy arises from physicians’ lack of control over how their time and energy is spent. Physicians face multiple competing demands on their time and the expectation of 24-hour engagement, leading to cognitive scarcity. Cognitive scarcity results from the inherent conflict between physician goals; namely to provide the best possible care for patients, and the structure of the healthcare system in which they work, which limits the time available to do so.”
With regards to strategies for self-monitoring the risk of burnout, we have added the following to Section 5. (Section 5. Educational Priorities and the Hidden Curriculum, Page 3, Paragraph 3, Lines 159-170).
“Education and training may also help oncology trainees and physicians learn how to monitor their own well-being and take action to protect it. Fisch proposed a model of buoyancy for oncology providers[44]. He describes buoyancy as being the opposite of burnout. According to Fisch’s model, several factors contribute to our well-being as oncologists. Some of these factors include: a sense of autonomy over your work, exercising skill, meaningful relationships, recognizing your fears and managing them, accepting loss and managing grief, and a sense of purpose. By being aware of these factors, and self-monitoring how we are doing in relation to these factors, Fisch suggests that we can maintain our buoyancy or resiliency against burnout. As educators, we must maintain awareness of how the hidden curriculum impacts oncologists’ perceptions of the value of monitoring and addressing such factors. By doing so, we ensure that the importance of this strategy in physician wellness is not diminished.”
Reviewer 2 Report
Commentary: ‘Training for Wellness’
This Commentary is interesting.
However, the Authors can consider some suggestions:
P # 1 TITLE: Training for Wellness
a suggestion:
‘Importance of Training for Wellness Among Pediatric Oncology Providers: Focus on Formal Education and Hidden Curricula’
P # 1 Abstract
An Abstract is missing – it needs to be added.
P # 1 Introduction
An Introduction is missing – it needs to be added
A definition of pediatric palliative care (PPC) according to the WHO could be included.
It should be highlighted that the PPC is based on the multidisciplinary management of the pediatric patient and the family’s somatic, psychological, spiritual, and social needs.
To improve palliative care services and prevent or reduce burnout in oncology providers, both formal education and informal curricula need to be integrated with medical teaching programs and standard oncology procedures.
Thank you
Author Response
Reviewer #2: This Commentary is interesting.
We thank the reviewer for their comment.
However, the Authors can consider some suggestions:
P # 1 TITLE: Training for Wellness. A suggestion: ‘Importance of Training for Wellness Among Pediatric Oncology Providers: Focus on Formal Education and Hidden Curricula’
We have taken the reviewer’s suggestion and changed the title to, “Training for Wellness in Pediatric Oncology: Role of Education and Hidden Curricula”.
P # 1 Abstract
An Abstract is missing – it needs to be added.
We have added the following abstract:
“Pediatric oncologists have the privilege of caring for children and families facing serious often life-threatening illnesses. Providing this care is emotionally demanding and associated with significant risks of stress and burnout for oncologists. Traditional approaches to physician burnout and wellbeing have neglected the potential roles of education and training in mitigating this stress. In this commentary, we discuss the contribution that education, particularly in the areas of palliative and psychosocial oncology, can make in preparing oncologists for the work that they do. We argue that by adequately providing oncologists with the skills that they need for their work, we can reduce their risks of burning out. We also discuss the importance of paying attention to hidden and formal curricula to ensure that messages provided in formal education programs are supported by informal training experiences.”
P # 1 Introduction
An Introduction is missing – it needs to be added
We would like to draw the reviewer’s attention to the first paragraph of the commentary, which serves as the introduction. (Section 1. The Weight of Pediatric Oncology, Page 1, Paragraph 1, Lines 25-34)
“In our (probably biased) opinion, being a pediatric oncologist provides truly the best of medicine: the nature of the conditions we treat and the care we provide means that we see our patients frequently, and over many years. In doing so, we have the honor of building close, long-term relationships with children and their families, accompanying them through some of the hardest moments of their lives. As oncologists, we work with families under significant stress, helping them to navigate complex medical situations and caring for children who face the risk of serious complications, including death. While we feel privileged to do this important work, we acknowledge that the intensity of this type of care can have a personal cost.”
A definition of pediatric palliative care (PPC) according to the WHO could be included. It should be highlighted that the PPC is based on the multidisciplinary management of the pediatric patient and the family’s somatic, psychological, spiritual, and social needs.
We thank the reviewer for this comment. We have referenced the WHO definition of PPC as the reviewer suggests in section 5. (Section 5. Educational Priorities and the Hidden Curriculum, Page 3, Paragraph 2, Lines 116-127)
“Education for oncology trainees and physicians has historically focused on a limited range of topics, narrowly centered on the diagnosis and medical management of cancers, often at the expense of topics like palliative care and psychosocial oncology. The World Health Organization defines palliative care as an ‘approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual’[28]. In order to provide the high quality palliative and psychosocial care that patients and their families require, it is clear that oncology trainees and physicians need dedicated training. Despite the need for this training, many organizations overseeing resident education have only recently recognized the need for palliative care education for pediatric oncology fellows. For example, the Royal College of Physicians and Surgeons of Canada only mandated palliative care education for pediatric oncology fellows in 2013[29].”
To improve palliative care services and prevent or reduce burnout in oncology providers, both formal education and informal curricula need to be integrated with medical teaching programs and standard oncology procedures.
In response to this important suggestion, we have edited our conclusions paragraph, as below. (Section 6. Conclusions, Page 4, Paragraph 4, Lines 172-188)
“Being surrounded by childhood death and dying clearly has a profound impact on the well-being of pediatric oncologists and trainees alike. Inadequate training not only has implications for the quality of care provided to children with cancer and their families but also for the wellness of those tasked with providing that care. Being inadequately prepared to navigate challenging patient care scenarios has been associated with trainee distress and may contribute to burnout. The risk of burnout is further compounded by a medical culture that doesn’t always support wellness. Palliative care and psychosocial aspects of oncology should be formally included in education programs to provide trainees with the skills needed to confidently approach the challenges they will inevitably face. Attention should also be paid to the informal and hidden curricula to ensure consistent messaging about the importance of palliative and psychosocial care as well as taking care of trainee and physician well-being. By providing high quality palliative and psychosocial oncology training, integrated into oncology teaching programs and routine oncology practice, we can improve the care we provide to our patients and families while reducing the risk of burnout in care providers. If pediatric oncology truly is the best of medicine, we owe it to ourselves and our patients to prepare as best we can for the work we are honored to do.”
