Burnout and Unrealistic Views of 'Budding Oncologists'

Fran Lowry

July 24, 2014

A survey of oncology fellows in the United States indicates that they underestimate the workload they will experience once they enter practice.

This unrealistic expectation might contribute to future professional dissatisfaction, burnout, and challenges maintaining a work–life balance, the researchers note.

The survey also showed that almost half of oncology fellows experience burnout in their first year of training, although this tapers off slightly as training progresses.

The survey, conducted by Tait D. Shanafelt, MD, from the Mayo Clinic in Rochester, Minnesota, and colleagues, was published online on July 21 in the Journal of Clinical Oncology.

These findings are particularly disturbing in view of the profound shortage of oncologists that is expected to occur by 2020, Reed Drews, MD, director of the hematology oncology fellowship program at Beth Israel Deaconess Medical Center and associate professor of medicine at Harvard Medical School in Boston, says in an accompanying podcast.

In Previous Survey, Oncologists 'Highly Satisfied' With Career

A previous survey of American oncologists conducted by Dr. Shanafelt's team found that, on the whole, oncologists are highly satisfied with their chosen career, as reported in Medscape Medical News.

In fact, 83% of the 1117 respondents reported being satisfied not only with their career, but also with their choice of specialty. The degree of satisfaction with career and specialty was higher for oncologists than for any other group of physicians studied.

However, only about one-third of the oncologists said they were satisfied with their work–life balance. This proportion is lower than any other medical specialty, according to a survey of American physicians (Arch Intern Med. 2011;171:1211-1213), and is lower than in the general American population (Arch Intern Med. 2012;172:1377-1385).

This dissatisfaction with work–life balance was linked to plans to reduce hours and leave current practice.

Having assessed the experiences of practicing oncologists, Dr. Shanafelt and colleagues set out evaluate oncology fellows.

High Response Rate

Oncology fellows were invited to participate in the optional survey after completing the 2013 Medical Oncology In-Training Examination (MedOnc ITE).

They were asked about career plans and professional expectations in the survey, and burnout, quality of life, fatigue, and satisfaction with work–life balance were assessed.

Of the 1637 medical oncology fellows in the United States, 1373 (83.9%) took the 2013 MedOnc ITE. Of these, 1345 (97.9%) completed the optional survey.

Results showed that 43.3% of fellows reported burnout in their first year of fellowship training. This rate decreased to 31.7% in year 2 and 28.1% in year 3 (P < .001).

The overall rate of burnout was similar in fellows and practicing oncologists (34.1% vs 33.7%).

Fellows reported more fatigue than practicing oncologists (P < .001), and lower overall quality-of-life scores (P < .001). However, fellows were more satisfied with their work–life balance than practicing oncologists (40.9% vs 34.8%; P = .0031), and were happier with their choice of specialty (89.4% vs 80.5%; P < .001).

Roughly half of the fellows (51.0%) said they intended to pursue an academic career, 35.0% planned to go into private practice, and 9.4% planned to go into veterans or military practice.

However, as the course of training went on, the desire for an academic career decreased and the intent to go into private practice increased. Fellows with higher levels of educational debt were less likely to choose a career in academic medicine and more likely to go into private practice.

The survey found that fellows underestimated the number of hours spent per week on administrative tasks at work, hours spent on work at home each week, and overnight call expectations. And they overestimated the amount of time they would have to spend on reading to keep abreast of changes in the field.

Overall, the team found that oncologists in private practice worked 6 hours more per week than fellows planning a career in private practice were expecting to work (62.9 vs 56.9; P = .025).

Median salary expectations were higher for fellows planning to work in private practice ($300,000 to $350,000) than for those planning to work in academic medicine ($200,000 to $250,000).

On multivariable analysis, increasing years in training, being male, and having children were associated with higher MedOnc ITE scores. Burnout, being older, and having more debt were associated with lower MedOnc ITE scores.

Reducing Stress in Budding Oncologists

In his podcast, Dr. Drews suggests that peer support groups, improved training in end-of-life topics, and improved teaching quality might reduce the burnout rate in the intense first year of clinical fellowship training.

"For some years now in our own fellowship program at Beth Israel Deaconess Medical Center, a psycho-oncologist, whose teaching time is supported by philanthropy, has joined fellows during patient visits in one of our high-volume subspecialty clinics, providing invaluable informative feedback to fellows who are conveying bad news to patients with metastatic disease," he reported.

"Additionally, we've offered communication skills retreats, morning sessions on the art of oncology, and evening book discussions as part of the training experience," he explained. "To what degree these efforts have reduced distress among our budding oncologists is uncertain."

Dr. Shanafelt and colleagues suggest that offloading a portion of a fellow's clinical responsibilities from the first to the second and third years of training might help reduce burnout. But Dr. Drews believes that such a move would only lead to increased burnout rates in years 2 and 3, and might disrupt focus and concentrated research time.

"Fellows intent on a successful academic career want less, not more, clinical responsibilities, particularly if they are to achieve research goals and compete successfully for grants and awards," he points out.

However, he acknowledges that career plans can change over time, and can be influenced by factors such as having children and educational debt.

As we train the next generation of oncologists, we need to "reduce burnout and dissatisfaction with work–life balance to avert a projected shortage of oncologists in the years to come and maintain an adequate stream of academic oncologists intent on improving patient outcomes through clinical and scientific discovery," Dr. Drews concludes.

Dr. Shanafelt and Dr. Drews have disclosed no relevant financial relationships.

J Clin Oncol. Published online on July 21, 2014. Abstract, Podcast


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