Burnout levels reach ‘tipping point’ among oncologists
Approximately 40% of physicians experience some form of burnout, according to national surveys.
However, the burnout rate among oncologists has reached an all-time high, with various surveys showing incidence exceeds 50%.
Burnout — which occurs when work or personal pressures exceed an individual’s ability to cope with them — can manifest as physical and mental responses.
Long-term, unaddressed burnout among clinicians can have devastating consequences, including chronic health conditions, emotional exhaustion, cynicism, a low sense of professional accomplishment, diminished quality of care and increased likelihood of early retirement.
Many hematology/oncology centers have prioritized efforts to identify and address burnout, Anthony Back, MD, professor of medicine in the division of oncology at University of Washington, told HemOnc Today.
“Clinical leaders at cancer centers are becoming increasingly concerned with the level of burning out and feel it has reached a tipping point where they need to address it,” Back said.
Oncology providers — including nurses — may be more susceptible to burnout.
“Oncology nurses have exposure to prolonged illness and loss, and we form special relationships with our patients. We do not just care for them, we care with them,” Beth Faiman, PhD, APRN-BC, AOCN, certified nurse practitioner at Cleveland Clinic and a HemOnc Today Editorial Board member, said in an interview. “Burnout is something I’ve seen more and more over the last few years among oncology nurses.”
HemOnc Today spoke with oncology care providers about the risk factors for and consequences of burnout, how this can affect quality of care, and interventions that may help prevent burnout at the individual and institutional levels.
Although physician burnout is not a diagnosed disorder, it is included in the “Problems related to life-management difficulty” section of International Statistical Classification of Diseases and Related Health Problems — a diagnostic tool maintained by WHO — because of its adverse effects and influence on a clinician’s health.
A survey conducted by Medscape showed the prevalence of physician burnout increased from 40% in 2013 to 51% this year. The survey revealed a burnout rate of 47% among oncologists, the seventh-lowest level among 27 specialties analyzed. However, when survey respondents ranked the severity of their burnout on a seven-point scale, oncologists reported the third-highest scores.
Greater workloads likely are a factor, Back said.
“One of the things happening in oncology is the increasing documentation and administrative demands,” Back said. “There [also] has been a massive amount of ‘new’ oncology. Fifteen new drugs were approved last year with new side effects, and they are all used quite differently. Patients have more questions, and oncologists are scrambling to learn about the drugs and if they are best for their patients.”
Burnout appears common across all levels of oncology care.
A study by Shanafelt and colleagues, published in July 2014 in Journal of Clinical Oncology, showed oncology fellows had an overall burnout rate similar to that of practicing oncologists (34.1% vs. 33.7%). A study by Aggarwaland colleagues showed 83% of radiation oncology program directors in the United States experienced moderate burnout.
Davis and colleagues surveyed 74 oncology nurses from a metropolitan cancer center,and they determined emotional exhaustion was highest among outpatient RNs.
Clinicians in all medical specialties experience burnout, but oncology is different, Ethan Basch, MD, MSc, director of UNC Lineberger Cancer Outcomes Research Program, told HemOnc Today.
For example, a study by Granek and colleagues — published this year in Journal of Oncology Practice — evaluated how chronic patient death affects oncologists. Their results showed that exposure to patient death motivated clinicians to improve patient care (66.7%), but it also led to exhaustion (62%), burnout (75.9%), and compartmentalization of feelings at work or at home (69.6%).
“There are some unique circumstances in oncology because of the severe nature of the disease. In many cases, it is the inability to cure the disease, as well as handling the toxicity of various treatments,” Basch said. “The toxicity of some treatments we have are worse than the disease itself and can lead an oncologist to feel repeatedly helpless.”
Compassion fatigue — the traumatization of nurses through helping others — is prevalent among oncology nurses and contributes to burnout, Faiman said.
“Nurses [can be] very sensitive,” Faiman said. “Many of us are female and we have motherly instincts, but we try to be professional at the same time. Balancing the demands of the job with personal responsibilities — and caring for patients at the same time can be stressful.”
Many nurses form bonds with patients, Faiman said.
“[Patients with cancer] often are not cured, so you are meeting with them day in and day out for years,” she said. “There have been studies that show burnout is rising among oncology nurses due to the chronic nature of the illness.”
Work setting also can play a role.
A survey of 1,117 oncologists — conducted by Shanafelt and colleagues, and published in March 2014 in Journal of Clinical Oncology — showed a higher percentage of those in private practice than academic practice felt burned out (50.5% vs. 45.9%). However, the difference did not reach statistical significance.
A majority of respondents were satisfied with their career (82.5%) and specialty choices (80.4%), but fewer oncologists in private practice indicated they would choose to become a physician again (79.2% vs. 87.5%; P = .0016) or be an oncologist again (77.5% vs. 85.1%; P = .0053). Further, academic practice oncologists who focused on one cancer type appeared more than three times as likely to develop burnout as those who treated multiple cancer types (OR = 3.24; 95% CI, 1.55-6.67).
Personal characteristics also are a factor.
In the 2016 ASCO Educational Book, Hlubocky and colleagues showed burnout was more common among oncologists who were younger, female or unmarried/nonpartnered, as well as those who had type A personality traits and behaviors. Further, clinicians may be at risk for burnout if they have limited decision-making capabilities, increased time in direct patient care, greater administrative responsibilities or use electronic medical record (EMR) systems.
“Oncologists have always dealt with tragic patient situations and documentation tools are not user-friendly, so they take a lot of time,” Back said. “The combination of these is driving the burnout.”
Strain of EMRs
The transition to an EMR system — although intended to streamline the documentation process — often is cited as a leading cause of physician burnout.
The EMR system is not assisting with patient care and instead puts more stress on physicians, according to Gabriel A. Sara, MD, medical director of the chemotherapy infusion suite at Mount Sinai West and assistant professor of medicine at Icahn School of Medicine at Mount Sinai.
“The system is supposed to provide instant information to all doctors and nurses assigned to a patient and, therefore, enhance patients’ care and outcomes,” Sara told HemOnc Today. “In reality, we end up putting in late hours every day to try to catch up with our documentation, and this is a significant additional factor for potential for burnout.”
In their March 2014 study, Shanafelt and colleagues found that each additional hour per week spent on administrative tasks increased risk for burnout by 5% among private-practice oncologists. An additional hour per week to complete these tasks at home increased burnout risk by 3.5% among oncologists in academic practice.
Another study by Shanafelt and colleagues — published last year in Mayo Clinic Proceedings — showed physicians were less likely to be satisfied with the amount of time they spent on clerical duties if they used electronic health records (OR = 0.67; 95% CI, 0.57-0.79) or computerized physician order entry (OR = 0.72; 95% CI, 0.62-0.84). Further, computerized physician order entry was associated with higher risk for burnout (OR = 1.29; 95% CI, 1.12-1.48).
Although EMRs can add to physicians’ stress, the impact of that stress varies, according to Wayne M. Sotile, PhD, founder of the Center for Physician Resilience in North Carolina.
“The electronic health record may be a brilliant idea and may one day create incredibly enhanced patient safety but, along the way, it adds a tremendous amount of work to an already overworked physician’s day,” Sotile told HemOnc Today. “About 50% of physicians are burned out because of this added work, but what about the other 50% who are not feeling burned out by it?
“If you peel back the onion, the physicians who are not burned out say to themselves, ‘I choose to work in oncology and will not feel victimized.’ Those who aren’t burned out find some way to adapt and convince themselves to improve their own attitude.”
Although the EMR may have created some hardships for physicians, any negative impact is a small contributor to burnout, Basch said. The combination of one’s workload and emotional stress is a bigger factor, he said.
“These systems are not user-friendly and they have not been built with the user in mind,” Basch said. “I absolutely agree that the current state of the electronic health record has contributed to burnout, but doctors got burned out long before this.”
Impact on patients
The top three signs of burnout are frustration, emotional exhaustion and lack of work satisfaction, according to Hlubocky and colleagues. Burnout can be expressed via fatigue, depression, pessimism and decreased productivity.
These symptoms can affect the quality of care a physician provides, as well as the outcomes their patients achieve.
For example, burnout makes a clinician less efficient and disengaged with their patients, Basch said.
“A physician may not be able to fully function and this may impact a patient’s quality of care if a doctor can’t do their job right,” he said.
Patient safety also can be jeopardized, Sotile said.
“Two things happen as burnout goes up: people get less intelligent and less interpersonally aware,” Sotile said. “You get more self-centered and self-focused. More mistakes are made and patients are less satisfied with their care. Collegiate collaboration along with patient care is instrumental to your career as a provider.”
Compassion fatigue also is a safety concern, according to Laurl Matey, MS, RN, CHPN, oncology clinical specialist at Oncology Nursing Society and adjunct faculty in the College of Nursing and Health Care Professions at Grand Canyon University.
“Sustained stress without intervention can lead to perceiving work as a drudgery — an emotional black hole to be avoided,” Matey wrote in an article published last year in ONS Connect. “Attentions to the needs of patients can become traumatizing, leading to passivity and disengagements. Work behaviors [that arise from] compassion fatigue include dreading work or certain patients, feeling less empathy, and work avoidance through increased use of sick days.
“Especially key to our ability to practice safety, compassion fatigue can cause memory problems, poor judgement, and loss of concentration and focus,” she added.
Poor coping mechanisms also can affect patients, Sara said.
“Some oncologists choose to build an emotional shield to avoid being vulnerable emotionally,” Sara said. “Unfortunately, the downside may be that patients might perceive that as a lack of compassion. This then can create an underlying tension in the doctor–patient relationship that can become a source of stress for both. Therefore, conversations about bad news or end-of-life care can become very difficult to conduct in a peaceful and productive atmosphere.”
If providers are not emotionally well, they may not be able to “worship the truth” when delivering a patient’s prognosis, Sara said.
“In oncology, we are still not good enough at being 100% honest with our patients about the future,” he said. “We either do not tell them the whole story or clarify vague points because it can be difficult to talk to them. In doing this, we create illusions, and eventually when the patient gets sicker, they may realize that the doctor did not have the courage to tell them the truth because they were too busy trying to be nice. ... We all need a strong mental and emotional background to be able to face the truth without feeling embarrassed and without losing compassion.
“The truth is a great power. [It] allows us not to burn out and be the best for our patients and allow them to heal,” he added. “Our job is to put that together so they die peacefully.”
It also is important to avoid making patients feel like they are a burden, Faiman said.
“An overwhelmed or emotionally exhausted nurse or physician cannot perform the demands of their job and will make the patient feel like a burden,” Faiman said. “Clinicians can become short tempered, too, in this case.”
Clinicians must ensure patients do not develop negative feelings about themselves because of a negative encounter with a nurse or doctor who did not appear focused or engaged, Faiman added.
“Poor interactions with patients happen, which is detrimental for the patient, for you or the team within your institution or hospital,” she added.
Burnout also is known to affect physician turnover and career satisfaction. This is particularly concerning due to a projected oncologist shortage in the United States.
Shanafelt and colleagues surveyed U.S. surgeons about why they would consider leaving their practice. The results — published in 2011 in Journal of American College of Surgeons — showed one in four surgeons considered leaving in the near future for a reason other than retirement. Burnout was the strongest predictor of intent to leave practice (OR = 2.5), followed by depression (OR = 2.1) and activity military practice (OR = 2.1).
“No one works like a physician,” Sotile said. “Research shows sevenfold more physicians work 60 or more hours compared with blue-collar workers. The problem is, burnout is not a chronic disease. Stress and career dissatisfaction are floating variables. We need to encourage and begin applying strategies that differentiate resilient people and families from those who are not.”
Interventions at the individual and institutional levels have been proposed to prevent and reduce physician burnout.
In a study published last year in TheLancet, West and colleagues pooled data from 52 clinical studies that evaluated interventions designed to reduce burnout among a combined 3,630 physicians.
The data showed any type of intervention led to reductions in rates of burnout (54% to 44%), high emotional exhaustion (38% to 24%) and high depersonalization (38% to 34%). However, structural or organizational interventions appeared more effective than those focused on individuals (P = .03).
Training at an institution level can help individual physicians cope, Back said.
“Oncologists should take part in programs that are easy for them to learn how to be resilient so they can, in turn, perform their work in a more resilient way,” he said. “Learning mindfulness skills and cognitive behavior skills can be crucial for preventing burnout and enabling them to perform that job effectively.”
Cleveland Clinic offers numerous courses that oncology nurses are required to complete, Faiman said.
“We must take courses on how to interact with patients, and we have companion classes so we can learn how to interact with our patients and with each other,” she said. “I think this is very helpful.”
Sotile suggested physicians develop personal philosophies to help keep them grounded, or attend retreats and support groups when necessary. He also recommended two strategies to promote physician resilience: countering daily hassles with uplifts and protecting relationship harmony.
“We need relationship support and harmony to stay resilient,” he said. “No one of us can be nearly as good as all of us when we are working effectively together. Anything to broaden and grow collaboration will promote resilience.”
Sara — who hosts a breakfast with his department once a month for colleagues to come together to talk and share experiences — agreed collaboration has played an important role in helping him prevent burnout.
“Burnout is more frequent than reported, and I host the breakfast so other doctors, nurses and fellows can come and discuss their emotions and difficult moments to help each other cope better,” Sara said. “A former fellow of mine told me years ago he was having a difficult time coping with a dying patient of his age, and he had a strong sense of failure and guilt. After counseling him and helping him cope, I suddenly realized that all physicians and nurses need this support. This is how I came up with the idea of our monthly breakfast. The breakfast has become a safe place to unload feelings and help each other.”
Having a strong support network at work also has helped Faiman.
“I have a network of doctors and nurses who I can talk to about the hardships or difficulties daily,” she said. “We try to celebrate the victories, but then when things are not so good, we band together and try to help each other figure out the next step and work with the patient as a team. Having the multidisciplinary team approach toward the care of patients is very helpful.”
Collaboration needs to come from personal relationships, as well, Sotile said.
“We help families shift to appreciating and honoring each other’s roles,” he said. “The classic burnout downward spiral is this: An oncologist feels disengaged at work because they focus on what’s wrong. They go home, talk about people at home, and the family at home takes a position against those who are against you. It shifts your thoughts about colleagues. ...
“What couples and families can do together is honor the work of what medicine is, while oncologists should also honor the contributions other family members are making and not be so focused on themselves,” he added.
Oncologists should allow themselves to have emotion and not bury their feelings, Sara said.
“We don’t necessarily need to sit down and cry with our patients every day, but if we are upset, we can express it in a mild, straightforward manner,” Sara said. “Actually, patients are comforted when they know we have feelings. It shows our humanity, and they realize how much compassion we have for them. It creates a closeness with our patients and enhances the trust factor. Allowing ourselves to feel our emotions markedly decreases the burnout factor.”
Impact on the future
The Association of American Medical Colleges reported in 2016 that the demand for physician services is growing faster than supply.
This is anticipated to lead to a shortfall of 61,700 to 94,700 physicians by 2025. This includes a shortfall of 14,900 to 35,600 primary care physicians, and 37,400 to 60,300 nonprimary care physicians. Expanded medical coverage, population growth and physician retirement are contributing to the shortages.
Burnout also stands to have an impact, Sotile said.
“Burnout should definitely be cited as one of the immediate risks,” Sotile said. “It is reasonable to believe, based on research, that curbing burnout increases job satisfaction and will probably prolong careers. In addition, the physician shortage calls for a heightened need for physicians to lead teams of providers, and burnout erodes leadership effectiveness.”
An aging workforce is expected to intensify the impending shortage of oncologists. More than 50% of oncologists are aged older than 50 years, according to The State of Cancer Care in America 2015 report released by ASCO.
Because burnout is common among oncology fellows, prevention strategies should be implemented as early as during medical training.
“Failing to address burnout and other quality-of-life issues among trainees and practicing oncologists can lead to serious workforce consequences,” the report’s authors wrote. “Oncologists experiencing such pressures may opt to reduce their patient volume or ultimately retire at an earlier age. Researchers have pointed to strategies including peer support systems, workload management guidance and increased care coordination to prevent and address physician burnout, but they generally agree that further research and testing is needed.”
Until such research is conducted, oncology providers should be mindful of the “critical role” they play in patient care, Faiman said.
“Understand that you can only do as much as you can do,” she said. “You are not failing if the patients aren’t doing well. You are still trying to do all you can for them and making their quality of life a little bit better while they fight their cancer battle.” – by Melinda Stevens
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For more information:
Anthony Back, MD, can be reached at firstname.lastname@example.org.
Ethan Basch, MD, MSc, can be reached at email@example.com.
Beth Faiman, PhD, APRN-BC, AOCN, can be reached at firstname.lastname@example.org.
Gabriel A. Sara, MD, can be reached at email@example.com.
Wayne M. Sotile, PhD, can be reached at firstname.lastname@example.org.
Disclosure: Back, Basch, Faiman, Sara and Sotile report no relevant financial disclosures.