SGO Issues Nov. 3, 2016
SGO on opioids: Balance efficacy, accessibility and safety
SGO Wellness task force addresses physician burnout in Gynecologic Oncology
Running on empty: using exercise to combat burnout | Leslie S. Bradford, MD
Former SGO VP and mentor Francis Major, Jr., MD, passes away
Registration, housing open for 2017 Annual Meeting on Women’s Cancer
Nominate a Colleague for an SGO Award
To address the unique needs of cancer patients in light of the federal government’s efforts to curb what has been called a “public health crisis” of opioid misuse, SGO in October issued the Clinical Practice Statement, “Opioid Use in Gynecologic Oncology; Balancing Efficacy, Accessibility and Safety.” The purpose of the statement is to promote safety without compromising efficacy of pain control by making gynecologic oncologists aware of current guidelines and proposed legislation, and urging them to address barriers to safe and effective opioid prescribing.
“Historically the problem with cancer pain has been undertreatment rather than overtreatment, and though existence of risk factors for opioid misuse have been documented in patients with cancer, there is currently no direct evidence that prescription of opioids to patients with cancer has contributed to the national issue of opioid misuse,” according to the statement.Earlier this year, the FDA announced an “Opioids Action Plan” to reduce the impact of opioid abuse, and the CDC released guidelines on use of opioids for chronic pain. Although mandatory prescribing restrictions for opioids have not yet been implemented, Massachusetts recently passed legislation that could serve as a model for other states.
“What remains to be seen, in terms of the letter of the law with any mandatory prescribing restrictions, is exactly how exceptions for cancer-related pain will be written; for example, terms like ‘active cancer’ or ‘active treatment’ can be ambiguous and could limit opioid access,” said Carolyn Lefkowits, MD, lead author on the statement, who added that such restrictions might influence how insurance companies and pharmacies handle opioid access for patients with gynecologic cancer.
“Whether such examples of compromised accessibility increase in frequency with increased opioid regulations, even when regulations are supposed to apply to non-malignant pain, remains to be seen,” she said. “This issue needs to be monitored as regulations go into effect.”
SGO recommends education efforts targeting patients and providers, as well as additional research and advocacy to promote safe and effective opioid use.
Dr. Lefkowits added that providers can get additional education by attending Risk Evaluation and Mitigation Strategies (FDA-REMS)-Compliant Continuing Education training for Extended Release/Long-Acting (ER/LA) Opioid Analgesics. This topic will also be addressed at several upcoming SGO conferences, including the Allied Health Professionals Workshop, the SGO Winter Meeting and the SGO Annual Meeting on Women’s Cancer.
With the publication of “Stress and burnout among gynecologic oncologists,” by SGO’s Gynecologic Oncology Wellness Task Force in the November 2016 issue of Gynecologic Oncology, lead authors Ilana Cass, MD, and Linda Duska, MD, anticipate that the 2017 Annual Meeting wellness-related sessions will help attendees find a better work-life balance.
Presentations by American Board of Obstetrics and Gynecology (ABOG) lecturer Tait D. Shanafelt, MD, director of the Mayo Clinic Department of Medicine Program on Physician Well-being, and a representative of The Energy Project, will be featured at the SGO Annual Meeting in National Harbor, MD, along with other wellness activities throughout the meeting.
The initial SGO survey that prompted the formation of the Wellness task force was conducted during the 2014 SGO Annual Meeting. According to the journal article, this 2014 survey of 369 SGO members and a 2008 survey of 7900 members of the American College of Surgeons (ACS), “established the high prevalence of physician burnout in gynecologic oncologists and surgeons respectively, affecting 32%–40% of responders.”
Dr. Cass noted that SGO and the subspecialty of gynecologic oncology have been ahead of the curve among other OB GYN subspecialties regarding wellness.
“In reviewing the data on physician burnout across specialties, the Task Force found that there has been a deep and robust effort among GYN ONCs to explore the topic from survey data among GYN ONC fellows, to women in gynecologic oncology,” she said. “The dual roles that many of us play with our patients, that includes both performing surgery and delivering ongoing oncology treatment, may make us more vulnerable to the effects of burnout. This unique facet of our profession, which affords us such continuity and connectedness with our patients and their families can, and does, take a cumulative toll on us a health care providers.”
The SGO article also noted that female GYN ONCs can be most at risk for physician burnout.
“This is part of a larger issue that we face in medicine regarding how our field evolves to embrace and reflect the increasingly large number of women providers in OB GYN,” said Dr. Cass. “The data support that women often have more responsibilities at home, both for children and for eldercare, which poses additional strain. I think encouraging more women to ascend to positions of leadership, seeking out innovative solutions to optimize work-hour flexibility, providing support for home-related tasks and encouraging meaningful mentorship, are all practical solutions.”
Among the stressors noted for all physicians are bureaucratic tasks, such as Electronic Medical Records (EMR), which have added significantly to the work demands of gynecologic oncologists.
“Personally, EMR has added four to six hours of work from home for me on weekends, which is echoed through the literature for many physicians,” said Dr. Cass. “I remain hopeful that my efficiency will improve with time, which seems to be the case for many physicians, and that the EMR will enhance systems-based care for my patients beyond my immediate interaction.”
And in a society that asks people to be “plugged in” at all times, the Gynecologic Oncology Wellness Task Force has tried to promote the tools to help our members recognize the value in separating work from self to enhance physician wellness. The Task Force publication specifically addresses the importance of learning from mentors within the Society who have the ability to be fully engaged and present with family and activities outside of work.
“Make a commitment to find those activities that are meaningful to you, re-energize and sustain you,” Dr. Cass said. “I think we have to decide not to simply settle for the stress inherent in being GYN ONCs, but to thrive and enjoy what our careers allow us to do with our lives.”
I used to be a runner.
For mile after mile, I would maintain a seven-minute mile pace, feeling the stress melting away. Hearing the rhythm of my feet hitting the road cleared my mind and put me in a sort of trance.
You get it. Perhaps you used to be a runner too–or a swimmer, or a cyclist. You were driven. You knew what it meant to feel pain and to keep going. Your sport taught you discipline and resilience. It pushed you to excel in your field.
But life happens.
About halfway through residency, I’d stopped exercising, and I was feeling the impact. I wasn’t sleeping well. I was cranky (weren’t we all?). My always supportive husband felt it too and bought me an indoor rowing machine—talk about an awkward anniversary gift (“I love you. No, you’re not fat, you just need to exercise”). And I started getting back into shape. I actually looked forward to my 4:30 a.m. row before a long day in the OR. I was exhausted from residency, but I finally felt healthy again.
I managed to maintain this routine through fellowship with early runs through the Boston Common, jumping over cobblestones and sewer rats, but then came kids. A new job. Boards. Grant applications. Clinic. More clinic. A few years into practice, I again found myself feeling cranky and irritable. I wasn’t sleeping, I felt unwell. After a work-related injury requiring physical therapy, and the recognition of classic signs of burnout, both physical and mental, I knew that I had to make a change. I had to make time for ME if I was going to be able to take care of others.
But “Physician, heal thyself” is easier said than done.
The importance of exercise is undeniable, especially as we confront the negative health effects of stress and burnout. In the lay press, exercise is lauded as a “miracle cure,” the “closest thing to a wonder drug,”  and there is data to back up these claims. Exercise improves outcomes in regard to decreasing pain, cardiovascular mortality, glycemic control for diabetics, potentially even improving brain health [2,3]. As A.A. Milne wrote in Winnie the Pooh, “A bear, however hard he tries, grows tubby without exercise,” and as oncologists, we are all well aware of the cancer risk associated with obesity . A recent meta-analysis has also demonstrated that exercise provides significant risk reduction in regard to breast cancer, colon cancer, diabetes, ischemic heart disease and ischemic stroke .
Nnenna Lynch, a former professional runner, wrote of her experience getting back into running after retirement, “I oscillated between intense focus and doing nothing.”  My own pendulum seems perpetually stuck in the “nothing.”
There are always excuses. I took the stairs today (pop open a bag of chips). It was a six-hour case (crack open a beer). Then there is the to-do list, which seems to always get longer. Exercise or finish charting? Exercise or make lunches for the next day? Exercise or sleep? If I do get out for a run, I plod, my knees ache, my lungs burn, and I ache for days. I have tried just about every form of exercise in an effort to get out of this rut. I signed up for a 30-day yoga challenge. I lasted 4 days. On the 4th night, I feel asleep on my yoga mat. The struggle is real.
The SGO has made a commitment to physician wellness, and over the course of the next few months you will read more about colleagues finding wellness. It is crucial to remember that the definition of and means for achieving wellness are very individual. Wellness is a state of mind, an awareness, which in turn leads to physical and mental health. Exercise can be one method for achieving wellness, for maintaining some degree of wellness. But there is a reason it is called “working out”. It takes commitment. It takes going the extra mile. Some element of pain is likely involved.
Personally, I’ve committed to a new, consistent exercise regimen. I often take my kids with me, but find that my arthritic black lab is far more forgiving when I need to slow the pace. My kids, on the other hand, are brutally honest (“Are we actually running?”). An interim analysis of this “experiment,” meaning my spouse’s feedback, is that even this modest amount of activity is greatly increasing the wellness quotient in our household.
I used to be a runner. Maybe I still am.
- Lynch, N. (2016). Advice From a Former Olympic Hopeful: Set the Bar Low. Retrieved September 27, 2016, from http://well.blogs.nytimes.com/2016/08/18/advice-from-a-former-olympic-hopeful-set-your-bar-low/
- Carroll, A. (2016, June 20). Closest Thing to a Wonder Drug? Try Exercise. Retrieved September 27, 2016, from http://www.nytimes.com/2016/06/21/upshot/why-you-should-exercise-no-not-to-lose-weight.html
- Nokia MS, et al. Physical exercise increases adult hippocampal neurogenesis in male rats provided it is aerobic and sustained. J Physiol. 2016 Apr 1;594(7):1855-73. doi: 10.1113/JP271552. Epub 2016 Feb 24.
- Lauby-Secretan B, et al. Body Fatness and Cancer–Viewpoint of the IARC Working Group. N Engl J Med. 2016 Aug 25;375(8):794-8. doi: 10.1056/NEJMsr1606602.
- Kyu HH, et al. Physical activity and risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events: systematic review and dose-response meta-analysis for the Global Burden of Disease Study 2013. BMJ. 2016 Aug 9;354:i3857. doi: 10.1136/bmj.i3857.
- Rath, K. S., et al. (2015). “Burnout and associated factors among members of the Society of Gynecologic Oncology.” Am J Obstet Gynecol 213(6): 824 e821-829.
- Murakami, Haruki, and Philip Gabriel. What I Talk about When I Talk about Running: A Memoir. New York, NY: Alfred A. Knopf, 2008. Print.
- National Race to End Women’s Cancer
“All I do is keep on running in my own cozy, homemade void, my own nostalgic silence. And this is a pretty wonderful thing. No matter what anybody else says.”
― Haruki Murakami, What I Talk About When I Talk About Running
By Susan Davidson, MD
Francis (Frank) Major, Jr., MD, passed away peacefully at his home on Big Pine Key, FL, on Oct. 18, 2016, two days shy of his 83rd birthday. He was a graduate of Georgetown University and New York Medical College. After completing his Obstetrics and Gynecology residency at Walter Reed, and five additional years of Army service, he received his oncology training in the United States Public Health Service at New York Medical College.
Frank then moved to Colorado in 1970 and served for 18 years as Chief of Gynecology and the Gynecologic Tumor Service at Denver General Hospital, an affiliate of the University of Colorado School of Medicine where he also had a faculty appointment. Here he was a much loved gynecologic oncologist and teaching physician to a generation of future OB GYNs, renowned for his surgical skills, clinical acumen, wonderful bedside manners, and generosity of spirit. In 1988, he transitioned to private practice but remained active in resident education until his retirement. Frank also joined the U.S. Army Reserves in 1981 as Colonel in the Medical Corps and served until his military retirement in 1993, including a year of active duty at Brooke Army Medical Center in San Antonio, TX, during the First Gulf War.
As his medical career progressed, Frank took on leadership roles in many of the professional organizations he joined and loved. He became a member of the Gynecologic Oncology Group in 1972 and served in many roles including Chairman of the Sarcoma Committee (1974-78) and Gyn Management Committee (1975-81). Frank also served as President of the Colorado Gynecologic and Obstetric Society (1984-85), President of the Western Association of Gynecologic Oncologists (1984-85), and Vice President of the Society of Gynecologic Oncologists (1988-89).
While family was his center, Frank was also a kind, wonderful mentor and friend to many He was always willing to share his Steamboat mountain retreat, his opinion (whether about medicine or the Broncos), and lend advice, usually over a shared meal that was sometimes of his own creation, especially later in life. After retirement, he continued to give of himself and became involved in medical missionary work, traveling to the Caribbean and Africa. Only in the last few years of his life did he truly slow down, relocating to Florida to enjoy the sunshine and the warm weather.
Frank was preceded in death by his wife Paula and is survived by his five children (Frank, Tom, John, Jim, and Jeanne) and their spouses, 14 grandchildren, one great grandson, and his sister (Mary Anne Hardy). He will be greatly missed.
Registration and housing is now open for SGO’s 2017 Annual Meeting. The meeting will be held March 12-15, with pre-session courses on March 10-11, at the Gaylord National Resort & Convention Center in National Harbor, MD, just minutes away from Washington, DC. (Please note that the meeting starts one day later than usual.) The deadline for early bird registration is Jan. 9.
The Society Gynecologic Oncology is seeking nominees for two awards to be presented at the 2017 Annual Meeting on Women’s Cancer®. The Harry Long Multidisciplinary Award recognizes outstanding SGO Member(s) for their contributions to multidisciplinary mentorship, collegiality or teaching in the field of gynecologic oncology. The Humanitarianism and Volunteerism Award will recognize individuals for their exemplary volunteer outreach efforts in women’s cancer care, research or teaching. If you know someone who is deserving of either award, review the nomination forms for eligibility and submission requirements and submit a nomination form to SGO Headquarters by Nov.18, 2016.