Disenfranchised Grief and Countertransference: Hidden Contributors to Oncologist Compassion Fatigue and Burnout

Oncologists suffer from high levels of compassion fatigue and
burnout. In the past, levels ranged from 35% to 45%.1 More
recently, in a 2023 survey, 59% of oncologists reported 1 or
more symptoms of burnout; 57% reported high levels of emotional
exhaustion; 34% reported they “have become more callous” toward
people.2 The financial toll is estimated to be up to $4.6 billion per
year due to costs associated with physician turnover, physician
shortages, and absenteeism.3 The COVID-19 epidemic, the increased
requirement to see more patients, the loss of physician autonomy,
long working hours, more time spent completing the electronic health
record (EHR), structural racism, institutional and gender bias
(including in compensation), and the exposure to frequent patient
deaths all contribute to burnout.1-4

Mitigating factors for oncologists discussed elsewhere focus on
recognizing the importance of physician well-being and providing
support for the practice, administration, patient care, and staffing.1,3,4,5
Strategies to build resilience, inclusion, and visibility in an organization
also improve fatigue and burnout and promote professional
satisfaction.3-6 Yet, the important contributions of unprocessed grief
and countertransference have received less attention in oncology
literature, though they are well recognized as important in psychiatric and psychological practice and palliative care (Table 1).7-10

Feelings of Grief
Oncologists have seen it many times: adult children weeping in the
exam room; nurses tearful after saying goodbye for the last time to
a beloved patient who is going to enroll in home hospice. As
oncologists, we offer our support and that of our staff.

We know the classic Kubler-Ross stages of grief that our patients
and families will manifest: denial (“It’s someone else’s CT scan!”);
anger (spouses or partners attacking you for “not caring” when you
delivered bad news); bargaining (“I’ll do anything if you enroll me
in the next trial”), depression; and (in some cases) acceptance
(Table 2).11

Grieving oncologists also manifest these stages. They may
experience intuitive grief with feelings of sadness, crying, and loss of
sleep. Or, perhaps more likely, they may have instrumental grief,
manifested not by crying, but by the need to do something.12
Instrumental grief is triggered by thoughts of lost patients and rarely
includes crying or the need to talk about the patient who has died.11
It may be impossible to tell that an instrumental griever needs support.
But if a colleague is avoiding usual social contact, seems to have a
shorter temper, or seems more distractible, they may be grieving.
Qualitative interview studies reveal the additional components of
oncologists’ grief, which include fiduciary duty to patients and feelings
of responsibility for patient outcomes that cause feelings of
powerlessness, guilt, self-doubt, and failure.13 That grief can spill over
to their home life, and oncologists may distance themselves from
loved ones.12 Caring for patients who are personal friends or colleagues
induces even more anxiety, difficulty defining boundaries, and
emotional exhaustion.14
Many among us have experienced these feelings. Some of us may
be unconsciously going through the stages of grief now, especially
the denial stage, which leads to compartmentalization and bargaining.13
Psychologically, it is less painful to obsess over what other choices
we could have made or which other treatments might have worked
better than to face our raw helplessness over the disease’s progression
and our patients’ deaths. Some data indicate that oncologists prefer
guilt to helplessness.15 It may feel less bad to be guilty, since one is
blaming oneself for failing the patient and can strive to do better next
time; helplessness is less amenable to reversal. These feelings can lead
clinicians to withdraw from patients they know are dying, or perhaps
to visit them less frequently in the hospital, to protect themselves.13
An oncologist’s grief is lonely. Stanislav Lazarev, MD, a radiation
oncologist at Icahn School of Medicine in New York, recently wrote:
“What lingers is not just the grief but also a profound sense of
isolation. You want to share your feelings…but finding an outlet can
be challenging. Your colleagues, as compassionate as they may be,
often have their own patients and concerns. You hesitate to burden
them. At home, you grapple with the decision to bring this sadness
into your family’s life. As a result, the grief remains contained, swirling
in a quiet space that offers no easy relief.”16 That was certainly my
experience throughout most of my career.
Dysfunctional Strategies for Grieving
In fact, I devised several strategies over the years to process my grief,
first as an oncologist and later as a palliative care and supportive care
clinician caring for patients with cancer. I was a woman physician in
the years when we made up less than 10% of the physician workforce,
at a time when there was significant concern about our ability to
withstand the rigors of medicine. So while I was an intuitive griever,
visibly crying was out of the question for me.
My first strategy as a house officer (resident physician) was fairly
primitive: I found a stairwell where, between patient visits, I could
cry unseen. That solution was not foolproof, but it worked most of
the time. Later, as a first-year oncology fellow, I was allowed only to
care for patients with advanced-stage disease who were not eligible
for studies. Of course, I lost many more patients than I had as a house
officer. But there was no one to discuss this with. I decided that instead

of looking for stairwells, when the lights dimmed at a concert, I would
reflect on my patients who had died. After several months of this,
I said to my husband, “Let’s not go to the symphony tonight. I don’t
have the energy to cry.” He, a poet, was understandably confused.
Only after I explained to him my system of evoking each patient in
turn, grieving them, and then moving on to the next, did I realize
how dysfunctional that solution was.

After abandoning that practice, I did my best to grieve as the
occasion arose, during the workday, the drive home, or the following
weekend. I thought I had my grief down pretty well, but unbeknownst
to me, my subconscious had concocted another scheme that protected
and healed me. I became aware of it only this year when, on a flight
from London to Boston, I found myself crying bitterly; I recalled all
the other flights on which I had done something similar. The sky had
become my safe place, my new stairwell where no one knew me, and
I was free to cry to my heart’s content. I have flown almost a million
and a half miles, for work and for pleasure, and most of that time
I was working or reading or watching films. And I did not consciously
choose to grieve; it just happened when it needed to, overflowing my
resistance and the barriers I had created to keep the grief in check.
I wonder whether, since I’m aware of it now, that solution will still
work. I’ll redouble my efforts to grieve in the moment. But I also
need to recognize when I must postpone those feelings, because the
next patient and family need me, and try to ensure I make time to
grieve later that day.
Maybe making a note to myself will work. I have a mindfulness
calendar that reminds me twice a day to breathe. Maybe a biweekly
reminder, grieve, will work as well.
Experiencing Disenfranchised Grief
Culture determines who is entitled to grieve a loss. Spouses, parents,
grandparents, children, and close friends and coworkers are generally
enfranchised, that is, expected to show signs of grief.
Disenfranchised grief, however, can occur when a person’s loss is
not openly acknowledged, socially validated, or publicly mourned.17
Oncologists and their team members who knew and worked with
a patient closely, often for years, are not expected to grieve openly

These providers may take a few hours to attend the wake or the
funeral, but they are not expected or encouraged to take days off for
bereavement. These providers are not offered condolences, and their
distraction and distress are rarely acknowledged. Deaths of patients
for whom they had countertransference (see below), of long-term
patients or young people, and unexpected deaths, as well as unrealistic
expectations of the patient’s family (eg, about a cure or the physician’s
responsibility for their loved one’s death) or high family needs all
contribute to oncologists’ unresolved grief.18
Implications for Oncologists
Oncologists and their teams may not even realize that they are entitled
to grieve. When grief remains unprocessed, there is often nothing left
for the next patient or family.13 Disenfranchised grief leads to
compassion fatigue and all the symptoms of burnout, such as anger
at work or at home, absenteeism, feelings of depersonalization
(ie, lacking empathy toward patients or anger at patients), and
emotional exhaustion (Table 3). Oncologists may find themselves
making rounds at the hospital in the early morning hours, before the
family arrives, to avoid the extra pain those encounters can cause.
Personal Solutions
Deferral, such as the compartmentalization I mentioned above, can
be a very effective coping strategy if used carefully. A more effective
way for clinicians to heal from their losses is to reach out to social
support networks or engage with the activities and people associated
Table 3. Symptoms of Burnout and
Compassion Fatigue
• Anger
• Absenteeism
• Depersonalization/callousness
• Emotional exhaustion
• Withdrawing from patients and families
I wonder how many of my oncology colleagues share this lack of
space, time, and ritual for grieving. I wonder if they even feel entitled
to grieve, and if so, where and with whom? The literature does not
provide answers, yet this may be one of the most important issues
to address if compassion fatigue is to be prevented.
Delaying Palliative Care Consultations
Oncologists may feel they have failed a patient when they have no
more therapies to offer against the cancer. Although intellectually,
these providers know that it’s medicine’s failure, not their own, that’s
not what it feels like. Guilty feelings and unconscious pangs of grief
can make it hard to tell patients that they are at the end of treatment.
These feelings also make it difficult to recommend that the time has
come to focus on making the most of their remaining time or to
recommend that patients change goals to optimize their quality of
life and alter their code status to do not resuscitate/do not intubate
(DNR/DNI).
Palliative care colleagues are happy to provide the support oncology
teams need, but unprocessed memories of painful experiences of
partnering with palliative care in the past, along with unrecognized
subconscious feelings of grief, guilt, failure, and helplessness may
deter oncologists from referring to palliative care,15,19,20 as making
that referral may mean admitting they failed.

with one’s faith. Other coping strategies include practicing self-care
(eg, sleep, nutrition, exercise), processing grief, and forgiving oneself.
Identify the activities needed to maintain physical, emotional, and
spiritual health, and commit to engaging in them. It may be helpful
to find someone to share the feelings of guilt, helplessness, and
hopelessness that will invariably arise. Forgive yourself and
acknowledge that you did the very best you could.
Anecdotally, the TV show Shrinking (Apple TV) offers a simple
practice: rather than try to suppress feelings of grief, allow yourself
to grieve fully just for the length of a favorite song and follow that
by engaging in vigorous activity. Repeat as often as needed.
Interpersonal Solutions
To begin to process grief, share it with colleagues, meet with the
family, make condolence calls, or send a card.21 Inform nurses and
social work colleagues about your preferences for support when your
patients are not doing well to help with anticipatory grief and whatever
transpires at the end of their care. ASCO’s Well-Being Task Force
created a pilot oncology group-peer-support virtual program supported
by trained peer facilitators.5,6 The biweekly, 2-hour resilience training
program took place over 3 weeks; it improved physician well-being,
and the 15 participants (11 of whom completed all the sessions)
reported high levels of overall satisfaction with it.
Organizational Solutions
Some surgeons use morbidity and mortality rounds to replace
rumination. They answer their what-ifs, explore their guilt, and label
bargaining as a useful learning from experience. If managing an
oncology program or leading a practice collaboratively, establish
a top-down expectation that grief is a natural part of the work and
requires regular attention, ensuring time and space for staff to address
grief. Staff can normalize discussing tough cases that cause them to
“play the tape over and over in their heads.” Airing the distress and
allowing the rational mind to explore irrational feelings enables
people to “put those feelings away” and make way for the sadness,
acceptance, and forgiveness they deserve.
Establish an office bereavement program that automatically sends
materials at specified times after patients’ deaths. Include information
about normal grief and how oncology staff might offer help for
bereaved families.22 Hold a remembrance service at regular intervals,
so that clinical and administrative staff can take time to grieve patients
they have known.23
Transference and Countertransference
What do these psychiatric terms have to do with oncology? We are
not therapists. Our job is to provide state-of-the-art therapy for our
patients and to treat the adverse effects of those therapies. Our
oncology care teams expect and can treat anxiety. We recognize
depression and demoralization, and we rely on our social work,
spiritual care, psychiatry, and palliative care colleagues to help patients
and families with these issues. Therefore, understanding patient
transference and recognizing our own countertransference were not
part of our formal medical or oncology training. Yet, these are key
elements of the therapeutic relationships upon which successful patient
treatment and outcomes depend.
Transference refers to how patients feel about us, ie, the “repetition of
feelings, attitudes, and behaviors attached to early formative relationships
in the context of a therapy relationship.”9 While psychological therapy is
usually what is meant, cancer treatment also qualifies as “a therapy
relationship.” According to Noorani and Dyer: “The power imbalance in
this relationship between a patient in need and a clinician looked to for
help can revive patients’ memories of relationships with earliest caregivers
and elicit powerful feelings of love, hate, longing, and dependency. This
is especially important in the oncology setting, where illness and disability
can threaten patients’ autonomy, self-esteem, and self-control, leaving
them feeling especially vulnerable.”9
Disenfranchised grief, guilt, and
unrecognized countertransference
contribute significantly to the development
of compassion fatigue and burnout among
oncologists. Oncologists must recognize
that they have not failed when their patients
die; medical science has failed.
A large part of the transference, therefore, is about how much we or
our actions remind patients unconsciously of positive or negative
experiences in their past.7,8 Consider these scenarios: Harold, a 55-yearold
man with stage III colon cancer, has followed your instructions
meticulously and praises you at each visit. But when his disease recurs,
he is furious with you and accuses you of incompetence and not caring.
If you knew that Harold’s parents had promised him unending success
if he just followed the rules, and his life until his cancer diagnosis had
been pretty perfect because he did, you might be able to take his attacks
less personally.
Suzanne, a 25-year-old woman with metastatic breast cancer, always
seems aloof and guarded. You might have expected this reaction during a
first visit, but she never seems to warm up to you, though she gets along
well with her infusion nurses. You may unconsciously remind Suzanne of
her stepmother, who did her best to “replace” Suzanne’s mother after her
mother died when Suzanne was 5 years old. Suzanne has always resented her.
But who is likely to have this information? With an understanding of
transference, we could take a step back, reflect on what was happening
with Harold and Suzanne, and reach out to our social work and nursing
colleagues to help us unravel the story. Without this understanding,
however, our day would be ruined; we are likely to take Harold’s accusations
of betrayal and worthlessness and Suzanne’s rejection to heart. With
enough of these encounters, compassion fatigue and burnout follow not
far behind.24

Countertransference is even more insidious. Countertransference is a
psychological phenomenon in which clinicians unconsciously allow their
personal feelings toward patients to dictate what those patients need
(Table 4). Countertransference can be positive or negative. It is expected,
normal, and will happen. It should not be a source of shame. It is the natural
consequence of being a human caring for a human, and our medical
knowledge does not mitigate countertransference. But if it goes unrecognized,
countertransference can lead to both substandard care for the patient and
burnout for the oncologist.
Table 5. Recognizing Countertransference7,9,10
• Experiencing intense emotion in a clinical encounter
• Feel that something unusual is happening
• Overcompensating
• Dreading interaction with the patient
Countertransference occurs when something about a patient
unconsciously reminds us of a relative, a teacher, or even a former lover.
We unknowingly react to them as we did to the person in the previous
relationship. Consider this scenario: when Cassandra, a woman of my
mother’s age and temperament, asked me to do things I would not normally
do when treating a patient (eg, allowing her to skip lab check-ins that were
inconvenient), I found myself acquiescing, though I did not know why.
I knew there was a risk, but it was what she wanted. This was an example
of a positive countertransference, in which I found myself having an unusual
attachment to the patient because she had so many of the same attributes
as my mother. Other similarities might include treating someone who is
close to your age, ethnic identity, gender expression, or background (eg, both
being of the same faith or a child of immigrants).19
I gave Cassandra my cell number, letting her know I’d be there for her
even when I wasn’t on service. This is termed a boundary crossing.8
Boundary crossing is a major component of burnout for clinicians who do
it often because they feel that’s what they owe their patients. If clinicians
understood why they felt this sense of obligation, they would be less likely
to make these offers, more consciously protect their private time, and suffer
less often from burnout.
Oncologists may unconsciously try harder to save patients for whom
they have positive countertransference and find themselves falling into
deeper despair when these patients die. Unaware of why they feel this way,
oncologists may go the extra mile to find a phase 1 trial for the patient and
are crushed when their efforts fail. These oncologists find it difficult to
have conversations about a poor prognosis and DNR/DNI choices even
when the patient has advanced disease that is no longer responding to
therapy and may have only weeks to live.
Negative countertransference is similarly destructive. Consider this
scenario: Mr. Nash unconsciously reminds you of your disparaging and
brutal physical education teacher. You dread seeing his name on your visit
Table 4. Countertransference*
• Subjective: when a clinician’s personal experiences cause an
emotional reaction to their patient
• Objective: the emotions a clinician experiences as a reaction to a
patient’s behaviors
• Positive: typically occurs when the clinician is overly supportive
of the patient
• Negative: when the clinician is disapproving of the patient,
becoming overly critical or trying to punish or reject them
*Adapted from Countertransference, www.betterhelp.com
Ask the patient, as well. Consider how they perceive you, what
has triggered them, or what assumptions they may be making based
on their previous experiences with people “like you.”
Talk with a social worker or a palliative care colleague about
encounters that feel unusual, emotionally charged, or painful. Consider
asking them to meet with the patient to unpack what triggered the
transference in the patient or the countertransference in the oncologist.
Recognize the factors within yourself that can trigger positive or
negative countertransference, and partner with palliative care or office
staff when seeing such patients. Feelings for a young mother, for
instance, may cause you to spend more time than necessary in her
room, affecting the schedule and the efficiency of the infusion room
for the whole day. Negative feelings toward a demanding, entitled
matriarch may cause enough frustration that maintaining a professional
stance becomes difficult. In these cases, it may be beneficial to avoid
meeting with these patients alone.
Anticipate a greater likelihood of frustration or anger when caring
for patients who trigger strong emotional responses. Extra time may
be needed for errands or getting to the airport, difficult conversations
with colleagues may need to be postponed, and tasks requiring more
patience should be delegated. It may be helpful to ask partners to
supervise homework or bedtime on days when your emotional energy
is particularly taxed.

Concluding Thoughts
Disenfranchised grief, guilt, and unrecognized countertransference
contribute significantly to the development of compassion fatigue
and burnout among oncologists. Oncologists must recognize that
they have not failed when their patients die; medical science has failed.
Accepting help to acknowledge and process grief—whether recognized
by others or not—and grieving together with staff and colleagues can
facilitate healing. By partnering regularly with social work and
palliative care teams, oncologists can better identify signs and
symptoms of countertransference in themselves or their colleagues
and choose to replace helplessness with constructive coping rather
than guilt. The more oncologists explore these pervasive influences
on their practice, unearth the reasons, recognize the potential dangers,
and partner with supportive colleagues, the more likely they will be
able to maintain joy in their work and avoid the pitfalls of compassion
fatigue and burnout.
Janet Abrahm, MD, FACP, FAAHPM, FASCO, is a professor of
medicine at Harvard Medical School in Boston, Massachusetts and
a member of the Division of Adult Palliative Care in the Department
of Supportive Oncology at Dana-Farber Cancer Institute in Boston,
Massachusetts.
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