Physician Burnout

It is fortuitous that I was asked to write a guest editorial on doctor burnout a few days after I had completed a questionnaire on that very subject. The questionnaire was distributed through ASCO and based on the Maslach Burnout Inventory (MBI). The MBI was used by investigators led by Dr. Shanafelt of the Mayo Clinic.¹ Dr. Shanafelt's team surveyed 27,276 physicians, of whom 7,288 (26%) completed the survey. A wide distribution of physicians from all walks of life, including specialties in internal medicine, were represented. The researchers concluded that burnout is more common among physicians than among other workers in the United States. One in 3 physicians report symptoms and signs of burnout on questionnaires such as the MBI.

The signs and symptoms of physician burnout are commonly known but often not recognized by the affected practitioner.² They include:

• Physical and emotional exhaustion: the physician complains of being drained, depleted, or worn-out by work and not able to recover during non-working hours.

• Depersonalization: the physician develops a negative, almost callous or cynical attitude toward patients and their concerns. This is most often recognized by patients and their families as cynicism, sarcasm, and the feeling that the physician is put upon by the patient.

• Reduced sense of personal accomplishment: physicians begin to see their work negatively, without value, or as meaningless. They see themselves as potentially incompetent.

Ultimately, burnout is an erosion of the soul caused by deterioration of one's values, dignities, spirit, and will.

Physicians react to burnout in a number of ways. Some withdraw from their practices, reduce the workload, or leave the practice of medicine altogether. Others become less engaged with their patients and the profession and suffer a decline in the quality of their work. Some physicians turn to unhealthy and even self-destructive habits such as excessive alcohol intake or inappropriate use of prescription drugs or illicit substances. Some physicians consider suicide. Others may turn to colleagues and friends or family for help or seek professional counseling. The highest rates of burnout are reported among primary care physicians, including family physicians, general internists, and emergency medicine physicians.

Many theories are offered concerning the cause of physician burnout. Some psychologists see burnout at one end of the continuum, with engagement and fulfillment at the other. This suggests that all physicians, including oncologists, will move along this continuum, depending on the daily stresses that make up the practice of medicine.³ The following is a list of potential stresses that may specifically affect oncologists:

• Oncologists work in a profession characterized as having a high level of responsibility but little control over outcome. The practice of oncology is a tough job on a daily basis.

• Oncologists work with sick people all day long; we see and treat many patients who will not benefit and who will succumb to the disease.

• Medical oncology can be seen as “a jealous mistress.” Our training reinforces innate workaholic tendencies, creating tension between work and a larger life with family and community.

• Physicians are asked to be leaders in a health care system without receiving formal leadership skill training. By default, we have adopted a dysfunctional top-down leadership style.

• Physicians, especially oncologists, often make themselves the limiting step in the health care team. This creates non-stop pressure to perform at full capacity all day long.

• Physicians tend to isolate themselves from the rest of the patient care team by seeing the patient one-on-one behind a closed door.

• Financial incentives are confusing to many physicians. We must deal with multiple health plans with different formularies and referral and authorization procedures, all of which the patient is frequently unaware or doesn't understand.

• Physicians practice in a hostile legal environment that can cause us to order tests and perform procedures contrary to what we have learned in medical school, residency, and fellowship or through continuing education conferences.

• Documentation requirements lead to constant work overload. The need to document everything that we do at the time of service adds to this stress.

• Community oncologists are experiencing shifting organizational structures that can destroy years of effort invested into building a practice, working with a group of health care professionals and eroding the profitability of the medical practice.

• Health care reform that we read about in newspapers and talk about in the cafeteria tends to create uncertainty and stress because we don't know what to expect.

• The practice of medical oncology can become routine, stifling the creative juices that many of us had when we sought medicine as a career.

Given the many stresses and factors that can affect our satisfaction with a career in medical oncology, what can we do to remove or blunt some of the stresses and provide an atmosphere where burnout is reduced for the individual physician?