Oncologists Warned-Don't Take Burnout Lightly

Anthony L. Back, MD

In ever-growing body of research confirms what many oncologists have long suspected: the stresses of their profession produce an alarming rate of burnout.

These findings bode ill, not only for the nearly half of all oncologists who suffer symptoms of the condition, but also for cancer victims. Studies show that burnout increases medical errors and shortens patient lives. Worse, it may spur enough early retirements to exacerbate a looming shortage of cancer specialists.

Some employers have begun to experiment with anti-burnout initiatives, but it’s far too early to say what specific top-down policies, if any, can reduce the burnout problem in a cost-effective way.

There are, however, approaches that individual professionals can use to help themselves now while research teams refine their understanding of what causes burnout and what mitigates it.

Taking Burnout Seriously

“The bad news is that a serious problem exists. The good news is that we’re finally taking it seriously. We’re doing more research and, perhaps more importantly, we’re finally paying attention to the research and thinking about how to address burnout,” said Anthony L. Back, MD, a University of Washington oncology professor who is one of the most cited authors on doctor burnout.

Burnout among oncologists in particular has attracted renewed attention of late, thanks to a large survey and analysis that appeared earlier this year in the Journal of Clinical Oncology.¹

A research team led by Mayo Clinic professor Tait D. Shanafelt, MD, repeatedly asked 2298 oncologists (whose demographics mirrored those of the profession as a whole) to complete a 60-question survey. More than a third of them (1117) eventually answered all the questions, and nearly half (1490) provided some response.

In some ways, satisfaction levels appeared high. More than 80% of all responders said that if they could start life over and choose any career, they’d choose oncology all over again.

In other ways, however, the picture looked bleak. The survey answers provided by 484 oncologists (44.7% of those who answered the relevant questions) indicated some degree of burnout on the emotional exhaustion and/or the depersonalization domains of the Maslach Burnout Inventory, a widely used questionnaire that provides a standardized measurement of burnout.

Among those who study burnout, those dispiriting numbers came as no surprise. Prior surveys of both individual specialties and physicians as a whole have made similar findings.

Indeed, a 2-year-old national study based on 7288 surveys concluded that a virtually identical percentage of the nation’s total pool of doctors (46%) was suffering from at least some symptoms of burnout.² A sub-analysis of that study, which was also led by Shanafelt, actually suggested that oncologists suffered significantly less burnout than other doctors, but the tiny number of oncologists in the study limited the strength of that finding.

Affecting Physicians and Patients

Such high burnout rates pose numerous problems for both doctors and their patients.

Even mild cases of burnout can make people miserable, and severe cases often lead to serious health issues that range from anxiety or depression to alcoholism or even to suicide.^3,4

Burnout also reduces productivity and increases error rates. One study of surgeons in the United States found a very strong correlation between survey answers that indicated burnout and admissions of significant mistakes in the prior 3 months.⁵

Every additional point that a surgeon scored on a 33-point scale measuring patient depersonalization (one of the 3 big components of burnout) was associated with an 11% increase in errors reported. Every additional point on a 54-point scale of emotional exhaustion was associated with a 5% increase in errors reported. A longitudinal study of residents found a similar correlation between burnout and/or distress and errors, and that study noted that the burnout preceded the errors.⁶

Doctor burnout may also lead to—or at least worsen—future shortages of cancer specialists. The American Society of Clinical Oncology predicts that, if current trends continue, demand for oncologists will grow 42% by 2025 but supply will grow by only 28%.

The result, according to the organization, will be a shortage of nearly 1500 oncologists.⁷

If burnout rates lead to an unexpectedly high number of early retirements, that shortage could be far worse than predicted, and studies consistently show that burnout does lead people to retire early or, in some cases, to switch careers while they are still young.^8,9

General research into burnout among all types of American workers suggests that at least part of the problem for oncologists lies not in the specifics of medical work but simply in the increasingly stressful nature of modern life.¹⁰ Burnout has been on the rise among nearly every subset of Americans in the past decade.

Still, doctors seem more likely to suffer from the symptoms of burnout than American workers as a whole. A probability-based sample of 3,442 US adults that was used as comparison for the physician surveys found that only 27.8% of American workers showed symptoms of burnout and only 23.2% of them (vs 40.2% of doctors) expressed dissatisfaction with work-life balance.¹¹

The burnout rate among doctors appears particularly unusual when doctors are compared with other highly educated Americans. The general population sample found that burnout rates are 20% lower than average for people with bachelor’s degrees, 29% lower than average for people with master’s degrees, and 36% lower than average for people with doctorates other than MDs or DOs. Being well educated does decrease your chances of burnout—unless you are a medical doctor. Medical doctors are among the only highly educated professionals who have a greater than average chance of experiencing burnout.

Perfectionists

Some (or much) of the reason for high doctor burnout rates may well lie in the type of person who becomes a physician.

“The difficulty of getting into medical school ensures that most doctors are people who naturally drive themselves very hard and demand excellence from themselves and everyone around them,” said another major researcher in the field, Henry M. Kuerer, MD, PhD, FACS. “People like that accomplish a lot, but they can burn out in nearly any environment because they’re perfectionists and life is frustratingly imperfect.”

Additional Correlates

Shanafelt and his research team looked for other potential causes of burnout among cancer specialists in the oncologist survey data and found many factors that correlated significantly with problems among the sample as a whole.

Younger doctors suffered burnout more than older ones, women suffered it more than men, single doctors suffered it more than married ones, and childless doctors suffered it more than colleagues with kids.

Burnout rates also increased along with total hours worked, time spent with patients, and total weekly patient numbers. As for compensation, salaried doctors suffered less burnout than those who received salary and productivity bonuses, who, in turn, suffered less burnout than doctors with no base salary.

But when the researchers split most of the total group into 2 sub-groups—oncologists in academic practice and those in private practice—they found that the overall correlations would often intensify for one group and disappear for the other.

For example, the overall analysis showed a significant correlation between childlessness and burnout. The split analysis, however, showed a massive correlation in private practice—where childless oncologists were 55% more likely to suffer burnout—but no correlation whatever in academic practice.

The correlation between burnout and gender worked the other way. Women in academic practice were 65% more likely to burn out than comparable men, but women in private practice were no more likely to burn out than men.

Overall, oncologists in academic practice were significantly less likely to show signs of burnout than those in private practice, but the only factors that correlated strongly with burnout for both groups independently were youth and time spent seeing patients.

Each additional year of age consistently reduced burnout risk by 4% to 5%. A 50-year-old oncologist was thus 40% to 50% less likely to suffer burnout than a 40-year-old who, in turn, was 40% to 50% less likely to experience burnout than a 30-year-old.

Time spent seeing patients also correlated strongly with burnout. Each additional hour spent with patients per week increased the risk of burnout by 2% to 4%. Thus, all other things being equal, an oncologist who spent 35 hours a week with patients would be up to 40% more likely to suffer burnout than one who saw them for just 25 hours per week.

These findings struck the study team as potentially problematic as there is obviously no solution to a purely demographic risk factor such as age and no easy solution to overwork.

“The strong, incremental relationship between time devoted to patient care and burnout is concerning, especially given the projected shortage in the supply of oncologists during the coming decades,” the authors wrote.

“Reducing clinical work hours or the volume of patients seen may be a strategy to decrease burnout for individual oncologists but at the societal level could exacerbate the projected oncologist workforce shortage.”

Employers Taking Note

Burnout has, in recent years, attracted a growing amount of attention from both researchers and a wide range of employers.

Studies have found a number of factors that consistently lessen burnout among workers, factors such as giving workers some control over when they put in their hours or how they accomplish their assigned tasks.

Unfortunately, many of these abstract techniques have proved difficult to implement in many professional settings and appear particularly ill suited to the world of medicine.

A software company might be able to give programmers the flexibility to decide, on the spur of the moment, to take a morning off and make the time up later. A hospital, on the other hand, might have trouble explaining that policy to patients whose doctors missed appointments.

Control Over Work Environment

Providing doctors more control over the work they do looks even more difficult. Indeed, the trend across the profession is pushing doctors in the opposite direction, toward checklists and guidelines designed to standardize both diagnosis and treatment.

“Giving people a sense of control over their work environments is probably the most powerful institutional solution to burnout, but it will be challenging to do in a meaningful way,” said Back, the University of Washington professor.

“How can you give doctors a sense of control while insisting on constraints that govern time, treatment choice, and documentation requirements? I don’t know, but we need to do it,” said Back, who noted that electronic records may be a particular problem. “I’m hearing from doctors that the electronic medical record creates substantial new work that feels more like busy work than patient care.”

Still, there is some hope for systematic improvement. Some small studies suggest that health care organizations can reduce doctor burnout by systematically looking for its signs and intervening when those signs arise.¹²

And many such organizations are experimenting, sometimes formally, often informally, with efforts to reduce stress levels among medical professionals. Some are subsidizing healthier foods. Others are building gyms. Still others are bringing in experts in meditation or yoga or other disciplines designed to stimulate mindfulness.

Studies examining such tactics have yet to determine which, if any, will consistently prove themselves to be cost-effective tools for combating burnout across an entire organization. The underlying ideas, however, have proved effective in helping individuals combat burnout.

Indeed, for all the difficulties of overcoming burnout in the aggregate, the problem often proves manageable for individuals. Better still, the most effective strategies are often reasonably easy and highly enjoyable.

The first step requires people to periodically ask themselves whether they’re happy, and, if the answer is “no,” to look for the 3 signs of burnout: a low sense of personal accomplishment, a great feeling of emotional exhaustion, and a tendency to depersonalize patients.

Those who spot burnout should then begin testing common countermeasures to see what works. “The first thing to do is make sure you’re taking good care of yourself: sleeping enough, eating well, making time for some sort of exercise— but not some exercise you hate, an exercise you really enjoy,” said Kuerer, who is a professor of surgical oncology at MD Anderson Cancer Center.

“The next step is to force yourself to schedule plenty of activities you find rewarding. Spend quality time with your friends and family… There are plenty of times when overcoming burnout takes real work, often with professional help, but in a surprising number of cases, the entire key to restoring joy in your professional life is to lead a richer life outside of work.”

References

1. Shanafelt TD, Gradishar WJ, Kosty M, Satele D, Chew H, Horn L, et al. Burnout and career satisfaction among US oncologists. J Clin Oncol. 2014;32(7):678—686.
2. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377—1385.
3. Shanafelt TD1, Balch CM, Dyrbye L, Bechamps G, Russell T, Satele D, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54—62.
4. Oreskovich MR, Kaups KL, Balch CM, Hanks JB, Satele D, Sloan J, et al. Prevalence of alcohol use disorders among American surgeons. Arch Surg. 2012;147(2):168—174.
5. Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
6. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302(12):1294—1300.
7. American Society of Clinical Oncology. The state of cancer care in America, 2014: a report by the American Society of Clinical Oncology. J Oncol Pract. 2014;10(2):119—142.
8. Sharma A, Sharp DM, Walker LG, Monson JR. Stress and burnout in colorectal and vascular surgical consultants working in the UK National Health Service. Psychooncology. 2008;17(6):570—576.
9. Shanafelt T, Sloan J, Satele D, Balch C. Why do surgeons consider leaving practice? J Am Coll Surg. 2011;212(3):421—422.
10. Jayson S. Burnout up among employees. USA Today. Oct 24, 2012. http://www.usatoday.com/story/news/ nation/2012/10/23/stress-burnout-employees/1651897/.
11. Shanafelt TD1, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377—1385.
12. Dunn PM1, Arnetz BB, Christensen JF, Homer L. Meeting the imperative to improve physician well-being: assessment of an innovative program. J Gen Intern Med. 2007;22(11):1544—1552.