COMMENTARY

Cultivating Resiliency and Combating Burnout in Oncology

Kate M. O'Rourke

Disclosures

June 30, 2017

A young oncologist, 11 years past his medical oncology fellowship, works in an urban healthcare system and sees 120 patients per week. He just became a new partner and is working longer hours. He reports physical exhaustion, irritability, sadness, feeling ineffective, and insomnia. At home, he calls patients and is tied to his computer handling medical records. He has ceased all leisure activities, including his daily run by the lake. He has asked colleagues, "Is any of this worth it?"

This is a typical case of burnout, said Fay Hlubocky, PhD, a clinical health epidemiologist at the University of Chicago Department of Medicine, speaking on burnout at the annual meeting of the American Society of Clinical Oncology.

A Prevalent Problem

"From 32% to 78% of practicing oncologists worldwide experience symptoms associated with burnout," said Dr Hlubocky. The wide variation is due to differences in medical oncology specialty, practice setting, healthcare system, and screening tools.

32% to 78% of practicing oncologists worldwide experience symptoms associated with burnout.

In a recent meta-analysis involving 4876 oncologists in 14 countries, including the United States and the United Kingdom, 32% of oncologists had a high level of burnout, 27% had psychiatric morbidity (anxiety, depression, and insomnia), 69% felt stressed at work, 51% screened positive for depression, 44% had sleep problems, and up to 30% used alcohol in a problematic way.[1] Another recent study shows that nearly half of US oncologists report emotional exhaustion and/or depersonalization.[2]

In this video from ASCO 2017, Anthony Back, MD, a professor at the University of Washington who codirects the UW Center for Excellence in Palliative Care, talks about causes of burnout specifically among oncologists.

Burnout is characterized by three core domains: physical and emotional exhaustion, cynicism and depersonalization, and reduced sense of professional accomplishment.[3] The 12 stages of the burnout cycle, said Dr Hlubocky, are compulsion to prove one's self, working harder, neglecting personal care and needs, displacement of conflicts, revision of values, denial of problems, withdrawal, obvious behavioral change (fearful, worthless), depersonalization, inner emptiness, depression, and burnout syndrome.

Burnout negatively affects the physician, patient, and healthcare organization. It increases the risks for cardiovascular disease, chronic fatigue, cognitive dysfunction, insomnia, and gastrointestinal issues, as well as mental health issues, such as depression, anxiety, substance dependence, and suicide.[4]

"Health issues contribute to suboptimal patient care, including medical errors, a decrease in patient satisfaction, increased staff turnover, increased employee absenteeism, a decrease in performance, and recruitment and retaining staff challenges," said Dr Hlubocky. In a recent study of 115 residents, those who were burned out were significantly more likely to self-report providing at least one type of suboptimal patient care at least monthly (53% vs 21%; P = .004).[5] Another study, involving 83 residents, showed that high mental well-being was associated with enhanced resident empathy.[6]

Risk factors for burnout are both individual and organizational. "Females tend to present with emotional exhaustion and males with cynicism," said Dr Hlubocky. Burnout tends to appear more in younger doctors and in those who are single or unmarried. Organizational risk factors include extended work hours, increased patient care, increased occupational demand, increased time and use of electronic medical records, unclear job expectations, education debt, and the evolving medical landscape.

Cultivating Wellness Skills

Fixing the problem of burnout is difficult because it is a stable, complex, and insidious process and is challenging to recognize in oneself and others, but oncologists can cultivate various wellness skills to prevent or combat burnout. Both individual-focused and structural or organizational strategies can result in clinically meaningful reductions in burnout among physicians.[7] The most common interventions used are mindfulness and stress management–focused efforts, communication training, small group discussions, and modification of local practice and duty hours.[7]

Psychological resilience is a key element of physician well-being. "[Resilience] is a journey. It is a process. It is not something you cultivate overnight," said Dr Hlubocky. Building resilience to stress involves working on psychological skills, relationships, and stress inoculation, and paying attention to other factors that influence resiliency, such as supportive relationships within and outside of work and cognitive flexibility (see Video below and Table). Resilience interventions may include burnout education, work-life balance, adjustment of one's relationship to work, mindful practice, and acceptance of the clinical work environment.[8]

Table. Factors Influencing Resilience[9]

Supportive relationships within and outside of work
Cognitive flexibility
Realistic optimism/happiness
Facing fear
Moral compass
Religion/spirituality
Social support
Role models
Physical fitness
Brain fitness
Sense of meaning/purpose
Personality
Secure attachment (autonomy, competency)

Burnout involves not simply the interaction between the individual and organization but also the individual's attitudes, self-appraisal, and appraisal of others. "Resilience, in essence, emphasizes the individual's emotions and promotes the individual's sense of control, commitment, and self-efficacy, which further protects the individual from burnout," said Dr Hlubocky.

Brief daily actions can foster resilience. "What about simply asking oneself at the end of the day, 'What are three things that went well today?' Maybe it was a really great patient interaction that you had. Maybe it was the fact that clinic didn't take such a long time," said Dr Hlubocky. "Take the time to ask each day, 'What three things am I most grateful for?'" Writing a daily narrative of personal experiences in clinical practice is another daily action that can be helpful (see Video).

"The antidote to burnout is resilience. That means using the three components to combat those symptoms of burnout: vitality, engagement, and self-efficacy. Meditate, try to find some form of relaxation, and minimize administrative work as much as you can. If you can go home early, do so," said Dr Hlubocky. "Mindful responsiveness, resilience, and growth are important to your long-term development as a professional and as a person."

Ronald Epstein, MD, professor of family medicine, psychiatry, oncology, and medicine at University of Rochester School of Medicine and Dentistry, also believes that resiliency is a capacity that can be grown and that people can work on "their interior" to prevent burnout. Work changes can also be helpful, he said. Changing the work environment to combat burnout might involve changing physical ergonomics, cognitive ergonomics, team and interpersonal landscape, organizational mindfulness, and organizational structure and leadership. Institutional strategies to reduce burnout include focusing on values-driven leadership, decreasing regulatory burden, discussion groups, and team training.[7,10]

Dr Epstein and Dr Hlubocky believe that healthcare organizations should provide institutional solutions to combat burnout through the implementation of team-based oncology care, communication skills training, and effective resiliency training programs in order to mitigate the effects of stress and prevent burnout in oncology.[8] "Clinicians who are flourishing provide better care," said Dr Epstein. "They form more effective relationships between colleagues and patients."

Clinicians who are flourishing provide better care.

Dr Epstein said that clinicians should assess where they are on the work spectrum, with "burnout" on one end and "flourishing" on the other. What does it feel like when you are flourishing at work? What are your earliest warning signs of stress? Do your shoulders get tense? Does your handwriting start to deteriorate? What thoughts and feelings accompany these signs of stress? Being able to recognize the signs provides an opportunity to fight the problem of burnout. Clinicians should be on the lookout for unhealthy reactions and unhelpful behaviors that they feel they can't keep themselves from doing.

"Each of us has an inner operating system but we don't really know that inner operating system particularly well," said Dr Epstein. "The writer Anne Lamott once said that a mind is like a dangerous neighborhood—I don't like to go there alone. I think that is true for a lot of us." For a healthy life outlook, however, introspection is necessary.

"Mindfulness is not sitting on a cushion by a tranquil lake, as Time magazine would have you believe," said Dr Epstein. "It is actually the way that you interact with your colleagues, your patients, and yourself when the heat is on."

Drs Hlubocky and Epstein have disclosed no relevant financial relationships.

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