Staff Stress and Burnout
Mary L.S. Vachon
Christopher Sherwood
Stress in the care of the dying has been being studied for more than 30 years (1, 2). Recent research (3, 4) indicates that little seems to have changed in the last four decades. Some improvements have been made. However, at times, organizations for a variety of reasons, including economic concerns, may go through phases when they are more or less open and able to make the changes that might decrease staff stress. Caregivers need to take responsibility for dealing with some of their own issues and incorporating proven stress management techniques into their lives, making sure that the job of dealing with issues related to staff stress is not totally the responsibility of the organizations.
This chapter will provide a selective review of the literature showing that many of the stressors appear not to have changed in the last four decades and will then look at current research to do both, better understand the process of what is happening and attempt to remedy the situation, changing what can be changed. Research shows that younger caregivers have more stress (5, 6) and fewer coping mechanisms (5), so it is not surprising that there continues to be stress as new people come into the field. Issues inherent in responding to increasing number of patients with cancer, new treatment methods, “demanding consumers”, dealing with cancer as a chronic illness, overwork, coping with life and death issues, communicating with people who are at a critical and vulnerable point in their lives, and dealing with colleagues who can be both a major source of support as well as a major stressor in our lives (5) will not be easy to deal with. Both personal and organizational approaches will be required to prepare new caregivers for the field; to support those in the middle of their career as they are juggling many family and career issues; and to provide the senior members of our disciplines with an opportunity of their lives in which their rich experiences can be valued and used to provide wisdom for those who will follow in their footsteps and develop their own paths, from which we can all benefit. It is to the benefit of many of us that there will be sufficient resources and resilient staff to deal with our families and us when it is our time to avail ourselves of the skill of those in supportive oncology and palliative care.
Overview
This chapter will review a variety of models that caregivers might consciously or unconsciously follow in their practice of supportive oncology and palliative care; will review recent concepts of burnout (7, 8) and compassion fatigue (9, 10) differentiating burnout from depression (11, 12); will discuss the concepts of job engagement (7) and compassion satisfaction (CS) (13) and utilize a framework developed by Maslach et al. (7) to understand the general factors contributing to burnout, showing that many of the sources of stress and burnout in supportive oncology and palliative care have not changed in the last 30 years. Finally, works on job satisfaction in the areas of supportive oncology and palliative care will be reviewed and recent research on improving both organizational and personal coping will be discussed. In general, the focus in this chapter will be on recent literature; the history of the field and the literature have been reviewed elsewhere (14, 15).
Models of Caring
In their powerful book, Crossing Over: Narratives of Palliative Care, which describes the experience of palliative care in two settings in the United States and Canada, Barnard, Towers, Boston, and Lambrinidou (16) state, “palliative care is whole-person care not only in the sense that the whole person of the patient (body, mind, spirit) is the object of care, but also in that the whole person of the caregiver is involved. Palliative care is, par excellence, care that is given through the medium of a human relationship” (16, p. 5). The authors document the experiences of patients, families, and caregivers during some of their finest and not so fine moments. The reader comes to understand the humanity of all involved.
A more recent study of nurses in a Netherlands academic palliative care setting (17) was undertaken by Georges et al. to gain insight into the fact that many nurses were leaving, frustrated by the far-reaching medical orientation on the ward and feeling unable to provide the care they wanted to give. These nurses were not neophytes. They were generally oncology nurses aged 35–55 years and had been working on this unit from 6 months to more than 4 years. They raised questions about the benefits and burdens of the medical treatment with which they collaborated. This study challenges whether the assumptions of Barnard are completely generalizable at this point in time and may shed some light on some of the conflicts in supportive oncology and palliative care in the early 21st century. This study will be compared with that of Bernice Catherine Harper (18). Dr. Harper is a social worker, whose
initial work involved supervising other social workers at the City of Hope Hospital in California. Her initial work was in the 1970s, drawing from much earlier work done in the 1950s, and was updated in 1994. Harper carefully supervised social workers and developed a Schematic Comfort-Ability Growth and Development Scale in coping with professional anxieties in death and dying. Her model proposes “learning to be comfortable in working with the dying patient and his family must be preceded by a growth and developmental process or sequence including cycles of productive change, observable behavior, and feeling” (18, p. 124).
initial work involved supervising other social workers at the City of Hope Hospital in California. Her initial work was in the 1970s, drawing from much earlier work done in the 1950s, and was updated in 1994. Harper carefully supervised social workers and developed a Schematic Comfort-Ability Growth and Development Scale in coping with professional anxieties in death and dying. Her model proposes “learning to be comfortable in working with the dying patient and his family must be preceded by a growth and developmental process or sequence including cycles of productive change, observable behavior, and feeling” (18, p. 124).
Comfort-Ability Growth and Development in Coping with Professional Anxieties in Death and Dying
Harper has a six-stage model, taking the caregiver from being a neophyte in the first month of working in the oncology field to a stage of 10 years or more of practice. The process involves careful supervision with a focus on the care of the dying and implies that the caregiver wishes to become more involved at an emotional level with clients.
Stage I Intellectualization 1–3 months
Provides practical help. Generally, the clinician relates on an intellectual basis, rejecting any emotional involvement.
Marked by periods of brisk activities as the worker tries to manage latent anxiety by completely understanding the hospital setting, policies, and procedures, but at the same time familiarizing oneself with the disease and the physical aspects of death and dying. Ineffective coping and managing of anxiety results in withdrawing and not being able to speak with the patient and the family about death and dying.
At this point in the professional career caregivers might be seen as experiencing empathic failure, the failure of one part of a system to understand the meaning and experience of another (19).
Stage II Emotional Survival 3–6 months
The caregiver experiences trauma, often accompanied by guilt and anxiety.
As one confronts the reality of the patient’s impending death, one must confront simultaneously one’s own eventual death. The caregiver comes face to face with the reality that “but by the grace of God go I.”
Feelings of self-pity exist along with feelings of pity for the patient. These feelings often lead to feelings of guilt and frustration. “This traumatized state of awareness often fosters extreme hostility within the worker as one tries to ‘fight back’. With this emotional experience, stage I passes into stage II, thereby jolting the worker out of the inertia of intellectualization into the activity of emotional involvement. Without this, the emotional growth could not transpire” (18, p. 45).
Stage III Depression 6–9 months
The most crucial in the schematic growth and development scale–the “Grow or Go” stage.
Mastery of self is a real challenge in this stage and this requires a growing acceptance of death and an orientation to the reality of death and dying.
Some workers experience extreme anxiety, grief, and depression. They question their usefulness, and real ability to contribute and be helpful; and express anger, hurt, and inability to come to terms with the situation. The pain, mourning and grieving are a part of the regression of not accepting the loss and then a moving forward to accept death and dying.
Depending on how caregivers handle their feelings of depression, they may quit the job or learn to live with it.
Stage IV Emotional Arrival 9–12 months
Marked by a sense of freedom—freedom from the debilitating effects, which are inhered in the previous stages of the experiential growth process. The caregiver is now largely free from identifying with the patient’s symptoms, free from the preoccupation with one’s own death and dying, free from guilt feelings about one’s own good health, and free from incapacitating periods of depression.
The caregiver is not insensitive, rather the caregiver’s sensitivities have sharpened. Although one is not free from pain, one is typically free from its incapacitating effects. At this stage the caregiver has “appropriate” emotions and has the sensitivity to grieve and the resilience to recover. “In other words one has reached the stage at which one has the control to practice the art of one’s science” (18, p. 71).
Stage V Deep Compassion 12–24 months
Involves self-realization, self-awareness, and self-actualization. The developmental process involves the caregiver ‘doing for himself’. This growth process contains all the elements of stages I–IV plus personal values, self-reliance, and the realistic acceptance of life and death.
At this point caregivers have seen all the physical aspects of the illness and have come to know and understand that in some cases living can be more painful for the patient and family than dying.
“Stage V is the culminating point of all the growth and development that has previously transpired. The learning process was anxious, traumatic, painful, and depressing, but the product of the process in terms of professional growth and development is rewarding” (18, p. 83).
The caregiver’s behavior and performance are enhanced by the dignity and self-respect one feels toward the self, thus enabling one to give dignity and respect to the dying person.
The deep compassion felt by the caregiver toward the dying person is translated into constructive and appropriate activities on the basis of human and professional assessment of the needs of the dying person and the family.
Stage VI The Doer 8–10 years beyond stage V
Demonstrates inner knowledge and wisdom, inner power, and inner strength. “… there is reinforcement, enhanced wisdom and knowledge to the understanding of death and dying. There is less and less misunderstanding of death. The professional and caregiver see, understand and accept death as a part of life’s transitions” (18, p. 122). “In order to use what you know, you must know what you use”(18, p. 99).
This stage is the flowering of the health professional. It is characterized by “the mature seasoned professional who operates, acts, and reacts on the basis of maturity. Mature adults are well aware of self. They know where they have been, where they want to go and what they need to do to get there”
(18, p. 99). This person is able to work well with the sick, terminally ill, and their families.
“The Burned-Out Syndrome is not a point at issue. Professional growth and development of the seasoned health professionals prevent burnout because these professionals take each stage and each phase of growth and development in their stride and grow in the process. They are able to identify with the terrible events and diseases of the patients without letting these events destroy them, without getting ‘burned out”’.
Acceptance, competence, and trust are exhibited in stage VI.
To some extent, doers have learned how to gather from the universe what they need, to do their work. Their clients recognize something in them and give feedback information that can then be used to help others.
For some, “gathering from the universe” might mean plugging into an intuitive wisdom, which comes over time. Dr. David Cumes is a urologic surgeon, originally from South Africa where he learned about traditional ways of healing before coming to the United States and specializing at Stanford Medical Center, where he also taught. Cumes (20) writes about getting in touch with the Inner Healer and one’s intuitive wisdom, in part through wilderness trekking and connecting with what he calls the ‘Field’. He quotes The Bhagavad Gita “Whatever being comes to be, be it motionless or moving, derives its being from the ‘field’ and ‘knower of the field’. Know this.” Cumes speaks of us all being “knowers” of the Field.
“Not only are we in the Field, but the Field is in us. The cosmic Field seems to extend from us as an energy reservoir in space through which signals pass back and forth. We could divide the messages that traverse the Field simply into Knowable and Unknowable. Light, sound, radio, TV, electromagnetic pulses and chemicals as subtle as pheromones are some of the Knowable signals that travel through the Field.
Many Knowable “mini” Fields are encountered in nature. We see the marvel of a termite colony, where the Field of intelligence of the colony far exceeds the capacity of the nervous system of any singular termite … However, there are also Unknowable forces transmitted through the Field such as telepathic and healing energies, which science has been unable to define or measure” (20, p. 114).
Cumes writes of returning from a wilderness trek in Peru to a busy schedule of patients, one of whom was a young man requiring a lymph node dissection for a cancerous tumor Dr. Cumes had removed before going on his trip. He did the surgery. The next morning he woke up at 5:00 AM
“… with an unusual degree of clarity. In this wide-awake state I was unable to get back to sleep and lay restlessly in bed. I felt uneasy about something, but could not put my finger on it. I decided to go to the hospital to make rounds early. It was dark when I arrived at the hospital to visit Jim. The nurse wondered what I was doing at the hospital so early and accompanied me to his bed. As we entered his room, it was obvious that Jim had stopped breathing. The nurse had seen him shortly before I arrived and everything had been fine. We began to ventilate him immediately because his reaction might have been due to an oversensitivity to morphine, gave him a drug called Narcan, which reverses the effect of morphine. There was a dramatic response and Jim began to breathe immediately. He came to, confused and wanting to know what had happened, but none the worse for the experience.
When I left the hospital after the incident, I gave a sigh of relief and realized how different the outcome could have been if something had not awakened me that morning. I wondered if my sensitivity to messages from the Field had been increased after the past two weeks in the pristine wilderness of the Andes” (20, p. 120).
Cumes states that “All healing involves four factors: the healer, the patient, the place where the healing occurs and the presence of a universal Field that embraces both healer and patient” (20, p. 11).
Michael Kearney, a hospice physician, also tries to elucidate these concepts (21). He uses concepts in the new physics to describe the integration between the traditional medical model and the healing model, which can be applied in palliative care and its relevance to the relationship between the caregiver and the patient. “The quantum idea that ours is a participatory universe has implications for carers. Although there are still subjects and objects within the healing model, the boundaries may not be as clear as they are within the medical model. Caring now becomes a dynamic event. While the roles of ‘carer’ and ‘patient’ remain, there is also an interweaving of the two. The term ‘clinical objectivity’ is joined by that of ‘clinical subjectivity’, acknowledging a shared dimension to the healing encounter”.
Striving to Adopt a Well-Organized and Purposeful Approach versus Striving to Increase the Well-being of the Patient
A very different approach to caring comes from the work of Georges et al. (17). They reported that “the academic character of the ward, focus on palliative treatment of symptoms, and need to achieve a high turnover rate of patients because of high demand and reduced bed capacity seem to encourage nurses to adopt an attitude promoting a more rational approach to care”. The authors quoted an earlier study on an intervention on that unit by Van Staa et al. (22) as noting that, “Although the mission of the unit has been stated as: ‘to put the patient and his or her loved ones first in mind, heart and soul’, little attention had been given to substantial deepening of the philosophy of palliative care. Paying attention to emotions and questions of meaning and developing a therapeutic and relational approach were seen by the management committee as typical of the hospice movement. Therefore, it was thought that efforts must be directed essentially to the development of an instrumental approach involving developing care protocols and increasing outreach activities (22, 23). Therefore, nurses were much more preoccupied with issues of competence and other practical matters and developed task-oriented attitudes”.
The unit was having trouble retaining nursing staff. Two methods of practice described the nurses’ actual activity: the first was the more prominent, ‘striving to adopt a well-organized and purposeful approach as a nurse on an academic ward’ (n = 12); the second is ‘striving to increase the well-being of the patient’ (n = 2). Although the sample size is small, the issues presented may shed some very important light on some of the issues in palliative care and supportive oncology. The following section is adapted from reference 24).
The Striving of Nurses to Adopt a Well-Organized and Purposeful Approach in an Academic Setting
Several of the nurses adopted an academic attitude, underpinning their nursing practices with a scientific and professional rationale. They felt that it was important to use a ‘scientific’ classification system of nursing diagnosis, to formulate nursing interventions in relation to the diagnosis, and to work within the limits set by the policy of the ward and the hospital. They were concerned with appropriate bed utilization and attempted to make discharge arrangements at an early stage
to avoid unnecessary occupation of beds. Carrying out the nursing process in a professional manner was more important than investing in their relationships with patients.
to avoid unnecessary occupation of beds. Carrying out the nursing process in a professional manner was more important than investing in their relationships with patients.
Developing a Professional Attitude
The nurses took a rational approach principally directed at gaining information about patients’ symptoms and gaining insight into their problems. These nurses had a more detached attitude and tended to focus on identified tasks and problems. For example, when giving information to patients, nurses may pay much attention to clarity and completeness while failing to consider the emotional impact of the message.
Striving to Remain Objective
Patients’ health problems were described in a formal language. The nurses avoided speaking about problems that could not be labeled well because they were not sure members of the multidisciplinary team could understand them. They argued that being objective was more in accordance with current professional developments in the field of nursing. They used diagnostic instruments to establish their observations. This allowed them to feel more comfortable when speaking with physicians, to feel they were seen as being more trustworthy, and hence to be involved in the decision-making process. These nurses consciously strive to avoid allowing their feelings to have an impact on their response to situations.
Being Task Oriented
These nurses are mostly committed to improving the situation of patients by solving or reducing their problems. They find it important to see that their interventions actually do improve the situation. When it is not possible to find a solution for patients’ problems, for example, to achieve sufficient symptom control, especially pain, nurses feel powerless and feel that they have not been able to achieve something meaningful for patients.
Avoiding Emotional Stress
Coping with the emotional aspects of palliative care was a leading theme in the interviews with these nurses. The stress they experienced seemed to be related mainly to their appraisal of, and approach to, palliative care. Some said that the gravity of caring for dying patients would inevitably lead to burnout, so they did not plan to work too long in palliative care. They tended to distance themselves from patients by focusing on tasks and the treatment of symptoms. Some nurses explain that their experience has taught them to remain more professional and detached, while others decided consciously not to invest too much in their relationship with patients because it would be too demanding.
Embracing a Practitioner-Focused Perspective
Nurses found it difficult to distance themselves from their own beliefs and to learn to be available to discern the perspective of patients and the meaning of the situation for them. Working in accordance with rules, they emphasized the need to respect important rules of the ward. When, for example, patients mention that they are considering euthanasia, some nurses explain that patients first have to follow the procedures in the organization and then go on to explain them to the patient. “These nurses, by being mainly directed to using a rational and ‘scientific’ approach to their tasks, could fail to meet the real needs of patients and to pay sufficient attention to the development of a compassionate attitude. This perception, which was very much present on the ward, is mainly characterized by a distant approach towards patients and a well-developed self-awareness to work on one’s own development as a professional.”
Striving to Increase the Well-being of the Patient
Nurses who practiced under the second model striving to increase the well-being of the patient felt that it was important to use their individual capabilities, such as being sensitive to patients’ concerns, and adapted their approach to individual patients. They found that, when fully aware of the needs of patients, it was not difficult to explain them to other caregivers.
Care appeared to be a central concern for these nurses and a main source of satisfaction. They were aware that, thanks to their caring attitude, they could mean something to patients, even if only for a short time, and they felt this to be rewarding. The characteristics of these nurses are discussed in the following sections.
Adopting a Humble Attitude
To act in accordance with the needs of patients, these nurses put their own considerations aside and found a way to cope with their own emotions. They strove to adopt an unobtrusive approach and to show their availability to patients without forcing anything, even without expecting patients to answer their ‘invitation’. This concept is similar to that described by Roshi Joan Halifax and Barbara Dossey (25) “An unknown territory, death often produces unpredictable responses that challenge all of us. The ‘trouble spots’ are the ground for learning to open our hearts. As we open our hearts we learn to let go of our conceptions, and letting go is the basis of equanimity. It provides the deepest opportunity to practice the three tenets of not-knowing, bearing witness, and healing. Maybe we find ourselves a little more humble and wiser for it all” (25, p. 157).
Giving Attention to Patients and Their Experiences
This approach was shaped by sensitivity to the feelings of patients, trying to discover and understand what patients experience and why they react as they do. To be conscious of patients’ experiences requires being really present. Some nurses, for example, are concerned that giving inadequate or incomplete information to patients could badly affect the direction of their decision about further treatment. By their sensitivity to the experiences of patients they become more connected with them and try to really help them, even if they have to ‘break the rules’.
Being Available
Being available, truly present, appears to be a major virtue of nurses so they can perceive the troubles and needs of a patient. They speak about being sensitive to unspoken messages and about trusting their intuition. Being receptive to what is going on helps them see how they can contribute to the well-being of patients.
Valuing a Caring Attitude
The meaning that nurses assign to their work is mainly based on their experience as nurses and on their daily encounters with patient care. They developed a caring attitude on the basis of authentic relationships with patients.
Remaining Attentive and Thoughtful
To find solutions to the problems they are confronted with, these nurses used self-reflection, striving to adopt a patient-centered attitude and to improve their caring attitude. They were also attentive to the context of their work, particularly to what should be changed to make it easier to express a caring perspective.
Trying to Accept and Cope with Emotional Strain
Nurses recognized that by caring for patients whose life is limited they are exposed to painful moments. However, they tried to accept emotionally difficult situations as a part of their own reality and did not attempt to avoid them. They strove to remain ‘authentic’ and stay close to patients even if they could not alleviate their problems.
Reflections on a Comparison of the Two Models
A comparison of Harper’s (18) work with that of Georges et al. (17) shows that, while Harper’s model is very useful to describe the career path of some staff in supportive oncology and palliative care, there may be others who do not progress in the manner which Harper describes. From her perspective, these staff members may never have evolved beyond the first stage of comfortability. They are still involved in an intellectual approach to their role and are defending against allowing emotions to intrude. However, the nurses in the category striving to increase the well-being of the patient could be seen to be in Harper’s stage IV or higher in which they have “the control to practice the art of one’s science” (18, p. 71).
Part of the reason for the split between the two approaches to nursing may be due to the bureaucratization of hospice palliative care. Byock (26) notes that Max Weber, the renowned German sociologist, observed that while social movements evolve to meet the needs of the time, they continue only through the process of bureaucratization. “Routinization is part and parcel of a social movement’s success; with it comes stability, confidence and bureaucracy” (27). Some of the issues being confronted by the nurses in the Georges et al. study (17) can be seen as related to the bureaucratization and standardization of palliative care. Doyle (28) and Kearney (29) warned earlier that palliative care specialists needed to avoid becoming merely symptomatologists. The field needed to recognize that “We are, in the presence of death, working toward health-that balance of body, mind and spirit that is so much more than freedom from disease. For that reason I believe we have no choice but to be alert to and responsive to human spiritual needs” (28).
“… (I)t as though the dragon (that is the patient’s distress) also guards a treasure-something essential for that particular individual’s healing at that moment in time. It is suggested that if we in palliative medicine fail to accept this view, a view which allows that there may also be a potential in the suffering of the dying process, if we sell out completely to the literalism of the medical model with its view that such suffering is only a problem, we will be in danger of following a pattern which could lead to our becoming ‘symptomatologists’, within just another specialty” (29).
Stress, Burnout, and Compassion Fatigue
Response to stress in oncology and palliative care has been measured in a number of ways including measuring various aspects of stress, psychological distress, and burnout.
More recently there has been interest in the concept of compassion fatigue (9, 10). Compassion fatigue (9) has been used to describe a syndrome that shares some characteristics with burnout: depression, anxiety, hypochondria, combativeness, the sensation of being on “fast forward,” and an inability to concentrate. Garfield et al. (30) state, however, that in contrast to one who has burned out, the caregiver with compassion fatigue can still care and be involved. Wright (31), a clinical nurse specialist and trauma/bereavement counselor working in an Accident and Emergency Department in the United Kingdom, gives the following signs of compassion fatigue: ‘no energy for it anymore’; ‘emptied, nothing left to give’; ‘not wanting to go there again’; ‘feeling depleted in every dimension’; ‘too many questions and no answers’; ‘why am I doing this?’.
Table 61.1 gives the definition of terms related to burnout and compassion fatigue and their more positive aspects of job engagement and CS. Table 61.2 gives a list of symptoms reflective of compassion fatigue and burnout. Stamm (13) suggests that if compassion fatigue and burnout are combined there may be no energy available to sustain the vision of a better world, in which one could find satisfaction. Burnout, characterized by exhaustion, seems to make it impossible to envision a world in which one is not overwhelmed by an ability to be efficacious (40, 41). The lack of efficacy (individual or corporate) likely colors negatively a person’s view of his or her fit with a personal belief system (13).
Burnout and Depression
Brenninkmeyer et al. (42) differentiated burnout from depression. Given that the clinical picture of depression seems to reflect a general sense of self-defeat, they hypothesized that individuals high in burnout and low in superiority (how individuals see themselves in comparison to others) would experience depressive symptoms. Depressive symptomatology was highest among individuals high in burnout who experienced a decline in superiority. “Depression was more strongly related to superiority than emotional exhaustion and depersonalization. In fact, emotional exhaustion, which constitutes the core symptom of burnout, did not have a significant association with superiority” (42, p. 879).
They concluded “reduced sense of superiority and a perceived loss of status are more characteristic of depressed individuals than for individuals who are burnt out. It seems that burnt-out individuals are still ‘in the battle’ for obtaining status and consider themselves as potential winners, while depressed individuals have given up” (42, p. 879).
Two recent large European studies have assessed the overlap between depression and burnout. In a Finnish study (11), burnout and depressive disorders were clearly related. The risk of depressive disorders, especially major depressive disorder (12-month prevalence), was greater when burnout was severe. Half of the participants with severe burnout had some depressive disorder. Those with a current major depressive episode suffered from serious burnout more often than those who had suffered a major depressive episode earlier.
The Dutch study (12) involved 3385 employees in a variety of work settings; after controlling for background variables, the strongest predictor of all three burnout facets was current depressive symptomatology. Hospital personnel (mostly female with a high level of interpersonal contact) reported the most depressive symptoms. Independent of the effects of background variables and current depressive symptoms, having ever experienced a depressive episode further predicted current symptoms of two burnout facets: emotional exhaustion and cynicism. In addition, a history of depression in close family members independently predicted current symptoms of emotional exhaustion. The authors concluded that a predisposition to depression, as reflected by a personal and family history of depression, may increase the risk for burnout.
In a southern European study of oncologists (43), low psychosocial orientation and burnout symptoms (i.e., emotional exhaustion, depersonalization, and poor personal accomplishment in their job) were associated with lower confidence in
communication skills and higher expectation of a negative outcome following physician–patient communication.
communication skills and higher expectation of a negative outcome following physician–patient communication.
Table 61.1 Definition of Terms | ||||||||||
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