Cover Story

The psychology of oncology: Physician burnout is going unrecognized

Oncologists need to be aware of signs of burnout and make efforts to prevent it.

Approximately one-third of practicing oncologists experience a significant career burnout, according to data from a collection of studies.

Burnout is a “syndrome of emotional exhaustion, depersonalization and a sense of low personal accomplishment that leads to decreased effectiveness at work,” according to Tait Shanafelt, MD, and colleagues. The symptoms of burnout often go unrecognized and can be similar to those of depression and stress.

Tait Shanafelt, MD
Tait Shanafelt, MD. In one of Shanafelt’s studies of residents, 87 of 115 met the criteria for burnout.

Photo by Siddiqi Ray

The culture of medicine and health care offers challenges that often lead to physician burnout. It is common for physicians to put their personal lives on hold during residency and fellowship training, said Shanafelt, an assistant professor of medicine at the Mayo Clinic in Rochester, Minn.

“There is an assumption that life will get better at some point in the future, after medical school, or after residency or fellowship,” he told HemOnc Today. “Instead, physicians are faced with new sets of challenges at each stage of their careers. The mentality of delayed gratification that puts personal life on hold during training is perpetuated throughout their careers.”

Physician burnout can have negative effects on patient satisfaction and can also affect patient compliance with medical care and lead to an increase in medical errors, Shanafelt said. The negative effects of burnout do not stop at work, however.

“Although there are certainly professional consequences for oncologists, there are also potentially profound personal consequences with respect to [an oncologist’s] personal relationships and their own mental, emotional and physical health,” Shanafelt said.

Physicians are becoming aware that they are at risk for burnout and that burnout has consequences that affect the integrity of health care, according to an article published by Spickard et al in The Journal of the American Medical Association. “There is ample evidence that physicians are caught in a web of pressures including financial deficits, Medicare/Medicaid audits, concern over fraud and abuse, and malpractice suits in which they perceive little control,” Spickard and colleagues wrote.

In a 2003 survey, Allegra et al found that the rate of burnout in the U.S. oncology community exceeded 60%. The survey was administered to 1,740 oncologists, of which 22.6% responded. The results were published in the Journal of Oncology Practice.

The top three signs of burnout reported were frustration (78%), emotional exhaustion (69%) and lack of satisfaction with their work (50%). The most frequently cited causes for self-reported burnout included overwork, lack of time away from the office and reimbursement concerns.

Glen Gabbard, MD
Glen Gabbard

“Overwork and failure to set limits to what one takes on are characteristics that are inherent to the psychology of doctors,” Glen Gabbard, MD, a professor of psychiatry at Baylor College of Medicine, said in an interview. “Many doctors have a secret omnipotence in which they think they can triumph over disease and death. After wrestling with the ‘angel of death’ for many years, they realize they are losing the battle.”

Burnout is not specific to middle-aged physicians. In a study published in 2002 in the Annals of Internal Medicine, Shanafelt et al found that burnout was also common among resident physicians.

The researchers conducted a cross-sectional study using an anonymous survey mailed to residents at the University of Washington hospitals. One hundred fifteen residents (76%) responded, and 87 met the criteria for burnout. Those with measured burnout were more likely to report suboptimal patient care at least once monthly.

In a study published in the Annals of Surgical Oncology in 2007, Kuerer et al found that 28% of surveyed surgical oncologists reported having burnout. Furthermore, they found that burnout was more common among women (P=.031) and among surgeons aged 50 or younger (P=.029). More than 50% of the respondents also reported working more than 60 hours per week.

“There is an unwritten code of rules and expectations that we are taught,” Henry Kuerer, MD, PhD, a professor of surgical oncology at the M.D. Anderson Cancer Center, told HemOnc Today. “There is a mentality that the harder we work, the more patients we have, and that the more tired we are, the better physicians we are.”

Henry Kuerer, MD, PhD
Henry Kuerer

Recognizing burnout

The first step toward treating burnout is recognizing when it has manifest, according to Kuerer. “Burnout is a real-life, everyday thing,” he said. “As with most things in life, the recognition of a problem is the first step in prevention and recovery from the problem.”

According to Gabbard, one of the best definitions of burnout is “erosion of the soul.” He said physicians often reach a point after working many years when they realize the rewards of practicing medicine are not what they expected. They realize that they have less autonomy as they are feeling under the control of third-party payers, treating unhappy or ungrateful patients, and facing the threats of lawsuits, among other situations.

“Physicians have a sense of fatigue or emotional depletion because the world they expected has not been delivered,” Gabbard said. “The ‘erosion of the soul’ is equated with a sense of joyless striving.”

Cynicism, explosions of anger and unexplainable body aches are often symptoms of burnout, Gabbard said. Stress, anxiety, depression, substance abuse, broken relationships and loss of enthusiasm for work can all occur as a result of burnout as well.

“There is a lot of overlap between burnout, stress and depression,” Shanafelt said. “One may lead to the other. Physicians who are stressed are more likely to become burned out. Likewise, some physicians who are burned out may be more likely to become depressed.”

One of the primary signs of burnout is depersonalization, Kuerer said. When physicians do not feel the need to empathize with their patients or their families, they may treat their patients as “just another patient” rather than a person.

Patient safety

According to Charles Balch, MD, a professor of surgery and oncology in the department of surgery and the Sidney Kimmel Cancer Center at Johns Hopkins Medical Center, there is a correlation between burnout and withdrawing from both professional colleagues and their commitment to optimal patient care. As a result, he said, there is a link between burnout and adverse patient events.

Charles Balch, MD
Charles Balch

“This is an issue that all oncologists need to address more proactively,” Balch told HemOnc Today, “not just because it is good for our profession and our colleagues, but also because advanced stages of stress and burnout may have an adverse impact on patient safety and quality outcome.”

Balch said that there is no documented correlation between burnout and geographic location or hours worked. He said that burnout is an issue for physicians whether they are in a community-based practice or an academic-based practice.

Some of the factors that contribute to burnout vary by practice type, Shanafelt said. In private practice, oncologists have more challenges with reimbursement issues and patient volume, whereas oncologists in academia are challenged by job security related to research and maintaining grant support.

Other factors may affect all physicians, regardless of their specialty, Shanafelt said. These include loss of autonomy and the cumulative hours that they work.

“Frequently having to deliver bad news, frequently dealing with death and suffering, administering toxic therapies and being unable to cure many patients are some factors that may be specific to oncology, “ Shanafelt said.

“It would be interesting to compare the burnout rate of oncologists in Canada and other countries wherein universal health care — thus, absent dealing with insurance company merchants — and minimal malpractice litigation abide,” said Harry S. Jacob, MD, FRCPath (Hon), Chief Medical Editor of HemOnc Today. “I suspect the ‘P’ value would consist of several zeros.”

Negative effects

Substance abuse is a common offshoot of burnout, Kuerer said. Alcoholism affected approximately 7% of the physicians in Kuerer’s study. Drug addiction is common, but the most common addiction is to food, he said.

Balch said that physicians experiencing burnout may withdraw from others or display inappropriate aggressive behavior to individuals with whom they interact. This can affect family relationships that might culminate in divorce, he said.

“For some, their actions become so extreme that they lose their privileges at the hospital and/or have their licenses suspended,” Balch said.

Among the more serious effects are those on the patients. Burnout can lead to physicians not being alert or attuned to the individual nuances of a patient’s stories, Gabbard said. They don’t know what is ailing the patient because they don’t listen or concentrate as well.

“They don’t have the same enthusiasm for treating patients, so the doctor-patient relationship suffers,” Gabbard said. “Of course the patient thinks it is personal and thinks ‘the doctor doesn’t like me.’ They are likely not getting the best care possible.”

According to Balch, an extreme consequence of burnout is physician suicide. He said that male physicians have the highest rate of suicide compared to men in any other profession and a higher rate than what is found in the general population. Prior to suicide, physicians often experience a depression from which they cannot escape and for which they do not seek counsel.

Reported Number of Hours Oncologists Spend in Patient-Related Activities Per Week chart
Source: Journal of Oncology Practice. 2005; 1:140-147.

Preventing and treating burnout

Leaders in cancer centers need to take a proactive position about addressing burnout, Balch said. Being proactive includes having a more formal mentorship program, getting annual physical examinations and being willing to seek professional help at an earlier stage of burnout.

“Part of the issue related to burnout is poor health,” Balch said. “Physicians, especially male physicians, are documented to do a poor job monitoring and caring for their health.”

Kuerer said that having discussions with other oncologists about the job would also have a positive effect. In addition, it would be important to discuss burnout with trainees, so they can be proactive at avoiding a burnout.

Away from work, physicians should pay attention to their personal lives. “It is critical that physicians schedule essential components that give their life meaning outside of work,” Kuerer said. “They need to identify and cultivate emotionally satisfying interests that provide meaning and balance, calmness and emotional well being. Our lives are driven by schedules, and these types of things need to be scheduled too.”

Shanafelt said to start by identifying what the personal and professional values and priorities are. When recognizing that some of these are incompatible, physicians should determine what sacrifices they are going to make to come up with a more integrative strategy.

“Oncologists who are able to successfully navigate the tension between their personal and professional life and develop an integrated strategy that brings balance between those two spheres are more resilient through the course of their careers,” Shanafelt said. “Those who work through these tough choices in a deliberate and proactive way are often more satisfied than those who are carried by a current.”

Proper training may also play a role, Shanafelt said. Some evidence suggests that oncologists who feel better trained in some tasks — such as delivering bad news and managing end-of-life care — are at lower risk for burnout than those who are not as well-trained, he said.

Similarly, there is evidence that those who are better prepared for the business challenges at their office are also at lesser risk, he said. This evidence suggests that modifying the training experience would be useful and result in less stress.

For those experiencing burnout, it is time for soul searching, Kuerer said. Establishing what brings you joy outside of work is the first step. Without these things, burnout becomes a vicious cycle, he said.

Gabbard said physicians need to analyze their practice situation and try to restructure it in a way that makes them feel empowered. Doing this may help physicians get more gratification out of their job, he said. In some circumstances, however, physicians do need to consider retirement or alternative careers.

Everyone is at risk

No specific age group is at a particularly high risk for burnout. Gabbard said that burnout is more common when physicians reach middle age and they realize their career is not what they had been expecting. Shanafelt said that a number of studies suggest that younger physicians are at greater risk, however.

“The reasons for this are unclear, since most of the studies were cross-sectional in nature,” Shanafelt said. “It could be due to cultural and contextual factors, such as a higher frequency of two-career families and different expectations of shared home responsibilities among young oncologists compared with middle-aged and older oncologists.”

Gabbard said that younger physicians are wising up and are more concerned about having enough personal time. In 2001, a survey showed that only 15% of medical students were concerned with the availability of free time. A similar survey in 2006 showed that 63% of students were concerned.

“That’s a striking difference, and reflects the fact that the new generation of medical students doesn’t want to follow the workaholic pattern of their role models,” Gabbard said. “They want to balance their time between work and personal life. That’s a big preventive measure right there.” – by Emily Shafer

POINT/COUNTER
Is burnout a well-recognized issue among physicians?

For more information:

  • Allegra CJ, Hall R, Yothers G. Prevalence of burnout in the U.S. oncology community: results of a 2003 survey. Journal of Oncology Practice. 2005;1:140-147.
  • Kuerer HM, Eberlein TJ, Pollock RE, et al. Career satisfaction, practice patterns and burnout among surgical oncologists: report on the quality of life of members of the Society of Surgical Oncology. Ann Surg Oncol. 2007;14:3042-3053.
  • Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358-367.
  • Shanafelt T, Chung H, White H, Lyckholm LJ. Shaping your career to maximize personal satisfaction in the practice of oncology. J Clin Oncol. 2006;24:4020-4026.
  • Spickard A, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. JAMA. 2002;288:1447-1450.

Approximately one-third of practicing oncologists experience a significant career burnout, according to data from a collection of studies.

Burnout is a “syndrome of emotional exhaustion, depersonalization and a sense of low personal accomplishment that leads to decreased effectiveness at work,” according to Tait Shanafelt, MD, and colleagues. The symptoms of burnout often go unrecognized and can be similar to those of depression and stress.

Tait Shanafelt, MD
Tait Shanafelt, MD. In one of Shanafelt’s studies of residents, 87 of 115 met the criteria for burnout.

Photo by Siddiqi Ray

The culture of medicine and health care offers challenges that often lead to physician burnout. It is common for physicians to put their personal lives on hold during residency and fellowship training, said Shanafelt, an assistant professor of medicine at the Mayo Clinic in Rochester, Minn.

“There is an assumption that life will get better at some point in the future, after medical school, or after residency or fellowship,” he told HemOnc Today. “Instead, physicians are faced with new sets of challenges at each stage of their careers. The mentality of delayed gratification that puts personal life on hold during training is perpetuated throughout their careers.”

Physician burnout can have negative effects on patient satisfaction and can also affect patient compliance with medical care and lead to an increase in medical errors, Shanafelt said. The negative effects of burnout do not stop at work, however.

“Although there are certainly professional consequences for oncologists, there are also potentially profound personal consequences with respect to [an oncologist’s] personal relationships and their own mental, emotional and physical health,” Shanafelt said.

Physicians are becoming aware that they are at risk for burnout and that burnout has consequences that affect the integrity of health care, according to an article published by Spickard et al in The Journal of the American Medical Association. “There is ample evidence that physicians are caught in a web of pressures including financial deficits, Medicare/Medicaid audits, concern over fraud and abuse, and malpractice suits in which they perceive little control,” Spickard and colleagues wrote.

In a 2003 survey, Allegra et al found that the rate of burnout in the U.S. oncology community exceeded 60%. The survey was administered to 1,740 oncologists, of which 22.6% responded. The results were published in the Journal of Oncology Practice.

The top three signs of burnout reported were frustration (78%), emotional exhaustion (69%) and lack of satisfaction with their work (50%). The most frequently cited causes for self-reported burnout included overwork, lack of time away from the office and reimbursement concerns.

Glen Gabbard, MD
Glen Gabbard

“Overwork and failure to set limits to what one takes on are characteristics that are inherent to the psychology of doctors,” Glen Gabbard, MD, a professor of psychiatry at Baylor College of Medicine, said in an interview. “Many doctors have a secret omnipotence in which they think they can triumph over disease and death. After wrestling with the ‘angel of death’ for many years, they realize they are losing the battle.”

Burnout is not specific to middle-aged physicians. In a study published in 2002 in the Annals of Internal Medicine, Shanafelt et al found that burnout was also common among resident physicians.

The researchers conducted a cross-sectional study using an anonymous survey mailed to residents at the University of Washington hospitals. One hundred fifteen residents (76%) responded, and 87 met the criteria for burnout. Those with measured burnout were more likely to report suboptimal patient care at least once monthly.

In a study published in the Annals of Surgical Oncology in 2007, Kuerer et al found that 28% of surveyed surgical oncologists reported having burnout. Furthermore, they found that burnout was more common among women (P=.031) and among surgeons aged 50 or younger (P=.029). More than 50% of the respondents also reported working more than 60 hours per week.

“There is an unwritten code of rules and expectations that we are taught,” Henry Kuerer, MD, PhD, a professor of surgical oncology at the M.D. Anderson Cancer Center, told HemOnc Today. “There is a mentality that the harder we work, the more patients we have, and that the more tired we are, the better physicians we are.”

Henry Kuerer, MD, PhD
Henry Kuerer

Recognizing burnout

The first step toward treating burnout is recognizing when it has manifest, according to Kuerer. “Burnout is a real-life, everyday thing,” he said. “As with most things in life, the recognition of a problem is the first step in prevention and recovery from the problem.”

According to Gabbard, one of the best definitions of burnout is “erosion of the soul.” He said physicians often reach a point after working many years when they realize the rewards of practicing medicine are not what they expected. They realize that they have less autonomy as they are feeling under the control of third-party payers, treating unhappy or ungrateful patients, and facing the threats of lawsuits, among other situations.

“Physicians have a sense of fatigue or emotional depletion because the world they expected has not been delivered,” Gabbard said. “The ‘erosion of the soul’ is equated with a sense of joyless striving.”

Cynicism, explosions of anger and unexplainable body aches are often symptoms of burnout, Gabbard said. Stress, anxiety, depression, substance abuse, broken relationships and loss of enthusiasm for work can all occur as a result of burnout as well.

“There is a lot of overlap between burnout, stress and depression,” Shanafelt said. “One may lead to the other. Physicians who are stressed are more likely to become burned out. Likewise, some physicians who are burned out may be more likely to become depressed.”

One of the primary signs of burnout is depersonalization, Kuerer said. When physicians do not feel the need to empathize with their patients or their families, they may treat their patients as “just another patient” rather than a person.

Patient safety

According to Charles Balch, MD, a professor of surgery and oncology in the department of surgery and the Sidney Kimmel Cancer Center at Johns Hopkins Medical Center, there is a correlation between burnout and withdrawing from both professional colleagues and their commitment to optimal patient care. As a result, he said, there is a link between burnout and adverse patient events.

Charles Balch, MD
Charles Balch

“This is an issue that all oncologists need to address more proactively,” Balch told HemOnc Today, “not just because it is good for our profession and our colleagues, but also because advanced stages of stress and burnout may have an adverse impact on patient safety and quality outcome.”

Balch said that there is no documented correlation between burnout and geographic location or hours worked. He said that burnout is an issue for physicians whether they are in a community-based practice or an academic-based practice.

Some of the factors that contribute to burnout vary by practice type, Shanafelt said. In private practice, oncologists have more challenges with reimbursement issues and patient volume, whereas oncologists in academia are challenged by job security related to research and maintaining grant support.

Other factors may affect all physicians, regardless of their specialty, Shanafelt said. These include loss of autonomy and the cumulative hours that they work.

“Frequently having to deliver bad news, frequently dealing with death and suffering, administering toxic therapies and being unable to cure many patients are some factors that may be specific to oncology, “ Shanafelt said.

“It would be interesting to compare the burnout rate of oncologists in Canada and other countries wherein universal health care — thus, absent dealing with insurance company merchants — and minimal malpractice litigation abide,” said Harry S. Jacob, MD, FRCPath (Hon), Chief Medical Editor of HemOnc Today. “I suspect the ‘P’ value would consist of several zeros.”

Negative effects

Substance abuse is a common offshoot of burnout, Kuerer said. Alcoholism affected approximately 7% of the physicians in Kuerer’s study. Drug addiction is common, but the most common addiction is to food, he said.

Balch said that physicians experiencing burnout may withdraw from others or display inappropriate aggressive behavior to individuals with whom they interact. This can affect family relationships that might culminate in divorce, he said.

“For some, their actions become so extreme that they lose their privileges at the hospital and/or have their licenses suspended,” Balch said.

Among the more serious effects are those on the patients. Burnout can lead to physicians not being alert or attuned to the individual nuances of a patient’s stories, Gabbard said. They don’t know what is ailing the patient because they don’t listen or concentrate as well.

“They don’t have the same enthusiasm for treating patients, so the doctor-patient relationship suffers,” Gabbard said. “Of course the patient thinks it is personal and thinks ‘the doctor doesn’t like me.’ They are likely not getting the best care possible.”

According to Balch, an extreme consequence of burnout is physician suicide. He said that male physicians have the highest rate of suicide compared to men in any other profession and a higher rate than what is found in the general population. Prior to suicide, physicians often experience a depression from which they cannot escape and for which they do not seek counsel.

Reported Number of Hours Oncologists Spend in Patient-Related Activities Per Week chart
Source: Journal of Oncology Practice. 2005; 1:140-147.

Preventing and treating burnout

Leaders in cancer centers need to take a proactive position about addressing burnout, Balch said. Being proactive includes having a more formal mentorship program, getting annual physical examinations and being willing to seek professional help at an earlier stage of burnout.

“Part of the issue related to burnout is poor health,” Balch said. “Physicians, especially male physicians, are documented to do a poor job monitoring and caring for their health.”

Kuerer said that having discussions with other oncologists about the job would also have a positive effect. In addition, it would be important to discuss burnout with trainees, so they can be proactive at avoiding a burnout.

Away from work, physicians should pay attention to their personal lives. “It is critical that physicians schedule essential components that give their life meaning outside of work,” Kuerer said. “They need to identify and cultivate emotionally satisfying interests that provide meaning and balance, calmness and emotional well being. Our lives are driven by schedules, and these types of things need to be scheduled too.”

Shanafelt said to start by identifying what the personal and professional values and priorities are. When recognizing that some of these are incompatible, physicians should determine what sacrifices they are going to make to come up with a more integrative strategy.

“Oncologists who are able to successfully navigate the tension between their personal and professional life and develop an integrated strategy that brings balance between those two spheres are more resilient through the course of their careers,” Shanafelt said. “Those who work through these tough choices in a deliberate and proactive way are often more satisfied than those who are carried by a current.”

Proper training may also play a role, Shanafelt said. Some evidence suggests that oncologists who feel better trained in some tasks — such as delivering bad news and managing end-of-life care — are at lower risk for burnout than those who are not as well-trained, he said.

Similarly, there is evidence that those who are better prepared for the business challenges at their office are also at lesser risk, he said. This evidence suggests that modifying the training experience would be useful and result in less stress.

For those experiencing burnout, it is time for soul searching, Kuerer said. Establishing what brings you joy outside of work is the first step. Without these things, burnout becomes a vicious cycle, he said.

Gabbard said physicians need to analyze their practice situation and try to restructure it in a way that makes them feel empowered. Doing this may help physicians get more gratification out of their job, he said. In some circumstances, however, physicians do need to consider retirement or alternative careers.

Everyone is at risk

No specific age group is at a particularly high risk for burnout. Gabbard said that burnout is more common when physicians reach middle age and they realize their career is not what they had been expecting. Shanafelt said that a number of studies suggest that younger physicians are at greater risk, however.

“The reasons for this are unclear, since most of the studies were cross-sectional in nature,” Shanafelt said. “It could be due to cultural and contextual factors, such as a higher frequency of two-career families and different expectations of shared home responsibilities among young oncologists compared with middle-aged and older oncologists.”

Gabbard said that younger physicians are wising up and are more concerned about having enough personal time. In 2001, a survey showed that only 15% of medical students were concerned with the availability of free time. A similar survey in 2006 showed that 63% of students were concerned.

“That’s a striking difference, and reflects the fact that the new generation of medical students doesn’t want to follow the workaholic pattern of their role models,” Gabbard said. “They want to balance their time between work and personal life. That’s a big preventive measure right there.” – by Emily Shafer

POINT/COUNTER
Is burnout a well-recognized issue among physicians?

For more information:

  • Allegra CJ, Hall R, Yothers G. Prevalence of burnout in the U.S. oncology community: results of a 2003 survey. Journal of Oncology Practice. 2005;1:140-147.
  • Kuerer HM, Eberlein TJ, Pollock RE, et al. Career satisfaction, practice patterns and burnout among surgical oncologists: report on the quality of life of members of the Society of Surgical Oncology. Ann Surg Oncol. 2007;14:3042-3053.
  • Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358-367.
  • Shanafelt T, Chung H, White H, Lyckholm LJ. Shaping your career to maximize personal satisfaction in the practice of oncology. J Clin Oncol. 2006;24:4020-4026.
  • Spickard A, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. JAMA. 2002;288:1447-1450.