Burnout Common Among Oncologists:
What to Do?

Liam Davenport

October 08, 2019

BARCELONA, Spain — Surveys show a high prevalence of burnout among oncologists, a concerning trend because it affects the care they offer their patients with cancer, delegates heard here at the European Society for Medical Oncology (ESMO) annual meeting.

The meeting had a special session dedicated to burnout among practicing oncologists — and ways to tackle it.

Burnout "significantly diminishes the oncologists' ability to deliver high-quality, patient-centered care, resulting in reduced patient satisfaction, safety, and organizational success," commented Ana Fröbe, MD, PhD, a clinical oncologist at University Hospital Centre Sestre Milosrdnice in Zagreb, Croatia.

It can also have "potentially profound, personal, and professional consequences," she continued. "We owe it to ourselves, our families, and our patients to pursue personal and organizational strategies to reduce burnout and promote personal health."

What Is Burnout?

The concept of burnout began to appear in the 1960s, said Pierfrancesco Franco, MD, PhD, Department of Oncology, University of Turin, Italy.

One of the first to describe the phenomenon was writer Graham Greene in his 1960 novel A Burnt-Out Case, which was set in a leper colony in the upper reaches of the Congo River. The author described extreme fatigue as well as loss of idealism and passion for one's job.

With time, it came to be linked to psychological deterioration and stress in caregiving contexts, Franco explained, with researchers in the 1970s such as Herbert Freudenberger and Christina Maslach emphasizing that burnout is not simply an individual stress response but rooted in workplace transactions.

In the intervening years, a number of experiential descriptions were developed; eventually, three key domains emerged that came to characterize the concept.

The first is what Franco termed the "centrality of exhaustion," with burnout an "end-state of exhaustion due to excessive demands on one's energy and recourses."

This is accompanied by depersonalization, which is characterized in a healthcare context by "compassion fatigue," in which the individual's compassion for the patient is moderated by emotional distance.

Finally, the emotional turmoil experienced by the caregiver leads him or her to question performance and ability at work, thus resulting in a negative self-assessment of his or her professional competence.

These concepts were crystalized by the inclusion of burnout in the 11th Revision of the International Classification of Diseases (ICD-11).

Emphasizing that it is an occupational phenomenon and not a medical condition, the ICD-11 states that burnout is "a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed."

It also emphasizes that burnout "refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life." 

High Levels of Burnout

Michiel Strijbos, MD, PhD, medical oncologist at St. Augustinus Ziekenhuizen in Wilrijk, Belgium, reminded the audience of the extent of the problem. He was a coauthor on a survey of younger oncologists that was presented 2 years ago at the ESMO meeting (Ann Oncol. 2017;28:1590-1596).

The survey was conducted among 595 oncologists age 40 years or younger from 41 European countries (62% women). It used the Maslach Burnout Inventory, which focuses on three key domains: emotional exhaustion, depersonalization, and personal accomplishment.

The results showed that 71% of respondents showed evidence of burnout, with 50% experiencing depersonalization, 45% emotional exhaustion, and 35% a sense of low accomplishment.

Strijbos said that risk factors for burnout in this survey included young age, long working hours, living alone, low appreciation at work, not enough vacation time, and geographical region, with burnout rates highest in central Europe (84%) and lowest in northern Europe (52%).

Factors that appeared to protect against burnout included access to support programs, a good work–life balance, and feeling appreciated at work.

At this year's ESMO meeting, similar findings were reported in another group of oncology care providers, a poster presented by researchers from Valencia, Spain.

This survey questioned 23 oncology nurses and nurse assistants, and found that 70% were at medium to high risk of burnout, with 70% experiencing emotional exhaustion, 45% depersonalization, and 55% lack of fulfillment.

Neglecting One's Own Needs

Burnout can be characterized as a multi-step continuous process, Strijbos said.

Initially, excessive ambition, in the form of the desire to prove oneself, leads to neglecting of one's own needs. Despite the first physical signs of exhaustion, there is a denial of basic needs that leads to withdrawal and a lack of social contact, followed by behavioral changes that are visible to relatives and colleagues, he explained.

Finally, the individual experiences depersonalization, in which life seems "mechanical," leading to inner emptiness and pathological overreactions, which result in mental and/or physical collapse, or burnout.

These changes are underpinned by physiologic alterations in serotonin and dopamine pathways in the brain that are similar to those seen in chronic stress and depression.

On a personal level, Strijbos said that burnout can lead to anxiety and depression, suicidal ideation, sleeping disorders, and physical sequelae such as increased low density lipoprotein (LDL) cholesterol levels and musculoskeletal complaints.

However, he reassured the audience that, in the vast majority of studies, no association between burnout and mortality has been identified.

On a professional level, burnout can affect patient safety and the quality of patient care, Strijbos continued. It can also lead to increased absenteeism, difficulties with colleagues, and job dissatisfaction.

Strijbos suggested that oncologists are particularly vulnerable to burnout, as among the demands of their job they are "often confronted with breaking the baddest of news." The trajectory of the disease often involves long and personal contact with patients and relatives, and there is a strong need to "keep up" with what he described as the "fast-changing treatment landscape."

Another Survey

More results on burnout were presented at the meeting by Franco, the University of Turin oncologist who is also chair of the European Society for Radiotherapy and Oncology's Young ESTRO Committee.

The survey involved 1560 ESTRO members from 94 countries, 1061 of whom were radiation oncologists. Of those, 828 (78%) completed the whole survey.

It used the PROfessional Quality of Life Scale (PROQoL) v 5.0, which takes into account a professional's work and personal environment and the environment in which they help individuals. It is is divided into subscales for compassion satisfaction, burnout, and compassion fatigue. This survey also used the Interpersonal Reactivity Index (IRI) and the 20-item Toronto Alexithymia Scale.

Results from this survey showed that 28.1% of respondents scored highly on the PROQoL in terms of compassion satisfaction, while 32.2% had high levels of secondary traumatic stress, and 30.9% had high burnout scores.

In addition, 12.9% of radiation oncologists in the survey had alexithymia, a disorder characterized by dysfunction in emotional awareness, social attachment, and interpersonal relating; 22.1% were considered borderline alexithymic.

Alexithymia was associated with significantly increased levels of burnout and secondary traumatic stress, as was higher personal distress on the IRI.

Participants with higher scores on the Perspective Taking and Empathic Concern subscales of the IRI had significantly lower levels of burnout.

How to Tackle Burnout?

Once burnout has been identified, how can it be treated?

Franco reviewed a number of studies that had tried various approaches:

  • A management support intervention in the Netherlands that involved interviews, meetings, and counseling, and achieved significant reductions in emotional exhaustion and depersonalization (J Appl Psychol. 2007;92:213-227).

  • In Norway, a one-day counseling intervention for individual sessions (or one week for group sessions) that focused on reflecting on personal situations/needs and psychotherapy significantly reduced emotional exhaustion and reduced the number of doctors on full-time leave. (BMJ. 2008;337:a2004).

  • Cognitive behavioral approaches have also been tested in medical oncology residents, with one study focused on stress management and communication training increasing self-efficacy and reducing communication stress, although burnout rates were unaffected. (J Health Psychol. 2010;15:1075-1081).

  • The greatest impact seems to have been achieved by Italian researchers, who devised an art and cognitive behavioral therapy approach to improve communication and increase comfort with nonverbal communication, as well as reduce anxiety and negative symptoms. Testing the intervention in 65 individuals working in oncology units, they were able to achieve a significant reduction in burnout (Psycho-Oncology. 2008;17:676-680).

Franco said that the take-home message from these studies is that reducing stress "is one aspect" of treating burnout, but it "may not be enough."

He emphasized that interventions should take place at both an individual and institutional level, with a "balance between service responsibilities and personal training."

In addition, Franco suggested that individual prevention training "should start early in a physician's career to develop a full skill-set to properly manage situations potentially leading to burnout, "with the available tools brought together into a more holistic, person-directed intervention."

Strijbos reports relationships with Ipsen, Bristol-Myers Squibb, Merck, Janssen, Novartis, IQVIA, Roche, GSK, RaySearch. Astellas, and Amgen. Fr ö be reports serving as a consultant/advisor to Astellas, Sanofi, Sandoz, Amgen, and Janssen.

European Society for Medical Oncology (ESMO) 2019 Annual Meeting: Presented September 30, 2019.

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