Physician Burnout

Author: Paul F. Engstrom MD
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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?

Job Satisfaction

As I completed the MBI provided by ASCO, I could honestly say that in my 40-year career in medical oncology, I have been able to adjust to the severe stresses that can lead to physician burnout. In general, oncologists feel that they have a high calling or a purpose in their career, and this is a source of immense power for endurance when facing stresses in medical practice. I have experienced great satisfaction in treating patients and their families, even when a cure is not possible.

Family and Community Orientation

I have found that maintaining a life outside the cancer center provides a perspective on the importance of my career and an opportunity to know and interact with both healthy and sick people in a church, school, or country club setting. Family activities have a generational perspective that can include the trust of a 4-year-old grandchild and care for an elderly parent. Hobbies such as gardening, choral singing, and community service have helped me maintain a balanced perspective on the importance of a professional career versus living life among friends and family.

Professional Relationships

I have been fortunate to live out my professional career in a comprehensive cancer center that provided opportunities for clinical research; student, resident, and fellow education; and leadership roles. Like most oncologists, I experience great satisfaction from interacting with my colleagues, particularly in multidisciplinary conferences to discuss patients with difficult management problems. The multidisciplinary tumor board and conferences provide a context for discussing difficult patients, thereby relieving the sense of isolation physicians may feel. I believe that this opportunity for interaction has not only made me a better physician but also widened my opportunities in oncology practice.

Schwartz Rounds

My institution also sponsors quarterly Schwartz Rounds,4 in which health care providers have an opportunity to discuss emotionally challenging cases or issues related to their work. A trained facilitator encourages the attending physicians, nurses, chaplains, and social workers to share their concerns. I find that improving communication is one of the most effective ways of reducing burnout for health care personnel.

A Role for Professional Organizations

By initiating the MBI survey, ASCO is providing a peek into the frequency and degree of stress in oncologists. Based on this information and the experience of leaders in cancer centers, a plan should emerge for countering burnout in oncologists. This should include programs that

  • Value, track, and support physician well-being
  • Institute regular monitoring for physician burnout
  • Create continuing education programs that teach preventive measures
  • Encourage physician support meetings, such as Schwartz Rounds
  • Provide training in leadership skills
  • Create specific programs to support oncologists experiencing symptomatic burnout

Hopefully, the ASCO survey will show that oncologists have fewer tendencies to experience burnout than primary care physicians. However, whatever the results of the survey show, we must be prepared to support our colleagues and work as a profession to prevent and counteract physician burnout.

References

  • 1

    Shanafelt TD, Boone S, Tan L. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012;20:19.

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  • 2

    Gunderman R. The root of physician burnout. The Atlantic 2012; August 27.

  • 3

    Drummond D. Physician burnout: why it's not a fair fight. Available at: http://www.thehappymd.com/physician-burnout-why-its-not-a-fair-fight/. Accessed January 30, 2013.

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  • 4

    Chen PW. Sharing the stresses of being a doctor. Available at: http://well.blogs.nytimes.com/2011/09/15/sharing-the-stresses-of-being-a-doctor/. Accessed January 30, 2013.

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Paul F. Engstrom, MD, is Professor and Chairman of Medical Oncology and Samuel M.V. Hamilton Chair in Cancer Prevention, at Fox Chase Cancer Center-Temple Health System.

The ideas and viewpoints expressed in this editorial are those of the author and do not necessarily represent any policy, position, or program of NCCN.

  • 1

    Shanafelt TD, Boone S, Tan L. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012;20:19.

    • Search Google Scholar
    • Export Citation
  • 2

    Gunderman R. The root of physician burnout. The Atlantic 2012; August 27.

  • 3

    Drummond D. Physician burnout: why it's not a fair fight. Available at: http://www.thehappymd.com/physician-burnout-why-its-not-a-fair-fight/. Accessed January 30, 2013.

    • Search Google Scholar
    • Export Citation
  • 4

    Chen PW. Sharing the stresses of being a doctor. Available at: http://well.blogs.nytimes.com/2011/09/15/sharing-the-stresses-of-being-a-doctor/. Accessed January 30, 2013.

    • Search Google Scholar
    • Export Citation
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