Dealing with our losses.

The repeated losses experienced by a clinical oncologist may constitute a significant source of personal stress. Studies documenting high stress levels on oncology services and the prevalence among physicians of alcoholism, cirrhosis, suicide, and marital discord lend urgency to the need to examine etiologic factors, clinical manifestations, and strategies for the management of job-related stress. Significant etiologic factors include death as an existential fact emphasizing our finite nature, the cumulative grief associated with repeated unresolved losses, the pressure of a health care system fueled by the medical information explosion, the inability to achieve the idealistic goals embraced by holistic medical care, stresses inherent in working as a "team," and an undermined context of meaning as an outcome of treatment failures. Clinical manifestations of stress are reviewed as an aid to early diagnosis. Strategies useful in the prevention and management of stress include the encouragement of increased awareness of stress in self and colleagues, the clarification of appropriate goals and priorities, encouragement of appropriate limit setting, the mobilization of collaborative input, the clarification of team roles and organizational patterns, the establishment of team support meetings and favorable working conditions, exercise, and the clarification and working through of previously unresolved personal psychodynamic issues. Differences between the work-related stress involved in clinical oncology as compared with hospice care are examined.