Why Are Young Oncologists Burned Out?

Lidia Schapira, MD; Timothy J. Moynihan, MD

Disclosures

November 17, 2014

Editor's Note: Why are oncologists burning out before they get into practice? A survey published in the Journal of Clinical Oncology[1] indicated that 43% of oncology fellows report burnout in year 1 of their fellowship, tapering to 32% in year 2 and 28% in year 3. Lidia Schapira, MD, associate professor at Harvard Medical School, spoke to Timothy J. Moynihan, MD, associate professor of medical oncology, Mayo Clinic College of Medicine; past program director for Medical Oncology Fellowship, Mayo Clinic, Rochester, Minnesota; and coauthor of the JCO study, to get his insights as to why so many young oncologists report burnout—and reconsider careers in oncology—at a time when oncologists are in increasingly short supply.[2]

Dr Schapira: What strikes me about your paper is that the rate of reported burnout is extraordinarily high. Are we using the right instruments to capture this data?

Dr Moynihan: The Maslach Burnout Inventory, which we used in this study, is the gold standard validated for the purpose of measuring physician burnout; whether that inventory captures all the factors critical to oncology is not known conclusively.

Dr Schapira: If one in two or one in three young oncologists are burned out, how is this likely to affect patient care?

Dr. Moynihan: We know that physicians in general medicine who are under more stress and are feeling more burned out are more likely to make mistakes,[3,4] but I don't know that there are oncology-specific data that demonstrate this. You would expect burnout to affect oncologists the same as it would any other group.

Dr Schapira: If the oncology fellows you train feel so much stress that they report being burned out, how would burnout affect their training and relational skills?

Dr Moynihan: Because stress and burnout can be caused by many factors, the real question is, what are the specific factors that lead to burnout in this individual? The intervention would vary depending on the factors involved. The questions are, what is the driver of each fellow's burnout, and how do you address it? Can we address that problem globally? And can we build the necessary skills for trainees to deal with burnout?

Is Personalized Intervention the Answer?

Dr Schapira: Just as we are now in an era of personalized medicine, we may be in an era of more personalized training. If we could identify, as you say, the drivers or sources of burnout, we could tailor our interventions to address them in a more specific and personalized way.

Dr Moynihan: Exactly. For someone in an academic practice, the driver of burnout may be the pressure to get that R01 grant, and an appropriate intervention might be to focus on improving that person's grant-writing skills. For a person whose burnout stems from end-of-life conversations, the intervention could address communication skills and improving their palliative care or hospice training.

Dr Schapira: More than 20 years ago, when Whippen and Canellos[5] reported the results of the first burnout study,their proposed solution was very simple: If people are burned out, they need more vacations, more time off. Does that solution resonate with you and your coauthors? Can more time off repair these problems?

Dr Moynihan: Whippen and Canellos strategized that time off would allow oncologists to refocus, rebalance, and possibly catch up on sleep and improve physical conditioning. However, I think the idea behind offering more time off is a temporizing strategy only; it will not serve well for 30 years of practice. I think the development of resiliency skills, as well as skills to better manage whatever is driving the burnout, would prove more efficacious.

One of the potential sources of burnout is the explosion of oncology knowledge. There is no way any person can keep abreast of today's oncology literature; 20 years ago, you could do that fairly easily. Now, just keeping up with clinical oncology, let alone the scientific developments, is a physical impossibility.

The inundation of data is one of the factors driving the trend to specialization, even in private practices. We are seeing fewer of the generalists in private practice.

Warning: Oncology May Be Hazardous to Your Life

Dr Schapira: It is very interesting to consider that an erosion of the sense of competence could lead to a feeling of personal failure, which is one of the hallmarks of burnout.

In interviewing applicants to oncology programs—in the spirit of full disclosure—should we say, "You are about to commit to a field with a high degree of reported burnout. Are you sure you have what it takes?"

Dr Moynihan: You bring up an excellent point. We don't want to scare people away. At the same time, we don't want to train fellows and 10 years later, they hate the field and can't wait to get out of it. That would be one of the worst outcomes we could have.

The way I measure success is whether an oncologist looks forward to going to work, every day or at least most days. Not just for a year or two, but for 30 years.

For that staying power, we may need to look for people who have resiliency skills, and by that I mean the ability to adjust to and cope with stressors in a productive manner. But again, if people don't have the resiliency skills in one particular area, that doesn't mean they can't be an oncologist. It's a matter of finding the right slot. The question is, can we identify a person's strengths and weaknesses to be able to guide that person into the right sector of the field?

Oncology is broad enough to accommodate a lot of different people, but how do we identify the right fit for a person? How do we know that this person shouldn't go into cardiology, or dermatology, or pathology, or radiology?

Dr Schapira: Returning to the issue of work-life balance, are oncologists who are involved in parenting young children more likely to burn out or less likely to burn out?

Dr Moynihan: During their fellowships is when many oncologists have children. I am not aware that burnout has actually been linked to whether oncologists have children during their fellowship. Anecdotally, we know that an additional burden of stress is associated with any change in family. Whether you get married, divorced, separated, have a child, have a second child—all of these factors change a person's stress level.

Debt can also be a factor. Our study found a link between the amount of debt fellows had and some of the factors regarding burnout. Again, it is possible that oncology fellows with a higher debt load have to work more, or experience more stress because of the bills. Of interest, foreign-trained graduates tended to have a little less stress and less debt burden.

Is Burnout Less Important Than the Bottom Line?

Dr Schapira: Your paper and other publications[6,7] are drawing attention to the topic of burnout among oncologists. Are people in positions of leadership paying attention?

Dr Moynihan: I think there is more attention being paid to these issues. Certainly, the Accreditation Council for Graduate Medical Education (ACGME) has driven efforts to acknowledge the problem and to address at least the work hours and stress of training. How well those interventions work is not clear yet, but by raising the awareness of the problem—both for the trainees and the program faculty—there is hope that some gain can be made. How well this will continue into practice is uncertain. Unfortunately, the work still needs to be done and is sometimes shifted to attending physicians. I wonder whether this increased workload leads to increased burnout among attending physicians.

I don't know that administrators are specifically focused on physician burnout. They are usually more driven by bottom-line and efficiency issues. In our own institution, we pay some attention to these issues, but nationwide I don't know how much attention is being given to burnout.

Dr Schapira: For someone who reports being burned out, what steps can be taken to restore his or her well-being?

Dr Moynihan: The first step is for the person to acknowledge that he or she has burnout and not just deny it. Typically, physicians just put their heads down and plow through. Recognizing burnout is an important step.

The second step is getting some assistance. Self-reflection, exercise, altered work schedule, and improved training in a particular area are all strategies that can be used to alleviate stress. We are certainly still at the recognition phase, but going forward, we need to implement individualized training or coaching plans to help oncologists decrease overall stress and burnout.

Dr Schapira: Can individuals experience burnout more than once? In other words, is there a relapse rate?

Dr Moynihan: We know that people who have burned out once can experience it again, but I don't know whether there are hard data on the relapse or recurrence rate. The key question is, can we design an intervention that would decrease the recurrence rate? Just as in an adjuvant chemotherapy trial in which investigators look at what decreases the tumor recurrence rate and improves survival, could we design a trial that would look at whether an intervention decreases the burnout recurrence rate and increases career survival?

I'm Burned Out and I'm Not Going to Take It Anymore

Dr Schapira: As a former program director and someone involved in the training of oncologists, do you think that fellows and young oncologists are speaking up and, "I am burned out. I need help"? Or does burnout go unrecognized?

Dr Moynihan: The culture clearly has changed. Oncology fellows now speak up about burnout—primarily because we frequently ask that question. ACGME requires us to ask that question. Ten years ago, nobody would admit to being too physically and emotionally exhausted to work. Now, fellows speak up, at least in a confidential forum, and the program director can confidentially intervene to do something about the person's problem. Residents in training, as well as fellows, are more willing to do this now.

Does the same thing apply to physicians in practice? I think the change in culture will eventually filter into practice. If, during training, fellows speak out, it is likely that they will be willing to speak out when they get into practice. But the trend may not have filtered up that far yet.

Dr Schapira: What advice do you have for those who are struggling?

Dr Moynihan: We all tend to be lousy at self-reflection, but if you find yourself dreading going to work, dreading the tasks you have to undertake, and feeling frustrated and stressed instead of upbeat and happy, these are signs of burnout. You should pay attention to signs and not just deflect them.

You need to stop and do something about it. What the intervention is or what processes you undertake to alleviate the stress should be specific to your particular needs.

Finally, you need to find meaning in your role in the world—not just professionally, but personally. Keep up with friends, and participate in your community in whatever way gives meaning to your life.

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