Morganna Freeman, DO, FACP
The pager beeped for what felt like the 100th time that day—I had just sat down to dinner, hopeful for a quiet break during my 24-hour outpatient call, and was already aggravated and tired. The hospital operator informed me there was a patient with breast cancer on the line calling about back pain. I groaned inwardly, hoping this would not be a long conversation. “What can I do for you this evening, ma’am?” I asked. The patient launched into a long description of multiple symptoms, none of which I could clearly identify as the reason for the call. Finally I broke in and asked, “Ma’am, is there something I can actually do for you tonight?” After a pause, she replied, “Yes, I am in pain, can’t you tell? I can’t believe this. You are one of the least sympathetic physicians I have ever talked to.”
This exchange left me stunned. Had I sounded unsympathetic? Normally, I prided myself on my ability to speak softly, demonstrate a caring attitude, and appear willing to serve my patients’ needs. Yet, it was late in the evening, I had spoken to multiple patients and families throughout the day, and I felt that my emotional bank account was overdrawn. This moment occurred during the middle of my first year of fellowship, and I felt overwhelmed by clinical responsibilities and a seemingly insurmountable learning curve. The question dawned on me: was I suffering from burnout?
Recognizing the Signs
As medical professionals, we know that this is a phenomenon to which few of us are immune. Physician burnout results in, and from, communication difficulties, mental overload, a shortage of time, and perceived loss of control. It has elsewhere been described as a “prolonged stress reaction,” characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment.1
Given the demands of patient care, documentation, personal life, and finances, it is no wonder that burnout happens to a lot of us. A recent Accreditation Council on Graduate Medical Education survey of residents’ assessment of wellness showed lower overall rates of well-being compared with the general population. A total of 24.5% of residents reported feeling “down, depressed, or hopeless” an average of 1 to 2 days during a 2-week period compared with 15.9% of the general population.2
As oncology fellows, we encounter the daily struggle of life and death, leaving us susceptible to emotional exhaustion. We often use depersonalization as a coping mechanism when our patients are dying. The overwhelming amount of knowledge we must master over the course of 3 years of training could certainly lead to feelings of reduced personal accomplishment. This all makes burnout seem bound to happen. Thus, in our endless drive to quantify medicine, the inevitable question is: what do the data show? And does this impact our practice?
Burnout Among Oncology Trainees
What contributes to burnout in oncology? There are a number of factors. On a daily basis, we are faced with life-and-death decisions, rely on toxic therapies with narrow therapeutic windows, and balance clinical judgement with patient preference (these may not always align). But despite our best advances, we may not be able to prolong life for many patients.3
Frequent exposure to death and suffering has the potential to lead to depression, cynicism, a sense of futility, and nihilism, 4
which impacts both our perceptions of skill and our ability to emotionally connect with patients. Time in training, too, may be a factor; even at the medical school level, significant erosion of empathy occurs between the first and final years of education,5
a concerning trend given the time point at which both burnout and frequency of patient encounters intersect. Burnout and emotional exhaustion have been seen in every branch of oncology: various studies have demonstrated a prevalence of 25% to 35% among medical oncologists, 38% among radiation oncologists, and 28% to 36% among surgical oncologists.6
So, how often is burnout happening at the trainee level? The results of a 2010 French survey of over 200 oncology residents showed that 44% of trainees reported emotional exhaustion and depersonalization, with 18% reporting abnormally high levels of each. The authors also found that burnout had a statistically significant association with the desire to either leave healthcare altogether or to change specialties,7
which may be related to the emotional toll that oncology practice can take. A 2014 US study published by Shanafelt et al in the Journal of Clinical Oncology
included 1345 fellows who previously participated in an American Society of Clinical Oncology In-Training Exam survey, referred to as the MedOnc ITE, which assessed fellows’ level of knowledge feedback on issues related to training. The study revealed a burnout frequency as high as 43.3% among first-year fellows. The frequency decreased as training advanced (31.7% in second-year fellows, 28.1% among third-years). A similar trend was seen with emotional exhaustion (42.7%, 29.4%, and 25.4%, respectively) and depersonalization (18.5%, 16.1%, and 13.6%, respectively). These improvements in burnout occurred in parallel with improvements in fatigue, satisfaction with work-life balance, and overall quality of life, which may reflect diminution of knowledge gaps and call responsibilities as oncology fellowship advances.8
What do we know about how burnout affects our practice? Studies have shown that depression is associated with medical errors9
and burnout contributes to impaired results on standardized testing. One study of internal medicine residents showed the effect size was roughly equivalent to an entire year of residency training (ie, median scores for burned out second-year residents were equivalent to intern scores).
Pointedly, longitudinal follow-up showed that residents who started with lower scores did not recover to the level of their colleagues during the course of training.10
Another study of burnout on internal medicine resident performance showed a correlation between emotional distress and medical errors. Each 1-point change on the 30- to 54-point burnout scales was associated with a 6% to 10% increase in the likelihood of reporting an error over a 3-month period,11
and burnout remained independently associated with errors after adjusting for fatigue and sleep deprivation.12
Given the prevalence of burnout and the impact on our practice, what can fellowship programs do to address this problem? Clearly, there is a need to address the stresses of caring for acutely ill or terminal patients as we learn the technical aspects of cancer care. Some studies have suggested that participating in peer support groups, receiving training on end-of-life (EOL) care, or learning about medical humanities during fellowship training may alleviate the emotional exhaustion that cancer care entails.
Peer Support Groups
We are expected to perform as strong, untroubled professionals even in our darkest and most selfdoubting moments. This can make it difficult to identify colleagues in trouble or admit that we may need help ourselves. Data reported at the European Society of Medical Oncology Congress in 2014 showed a troubling trend among young oncologists: burnout survey data revealed that 73.4% of trainees and 82.6% of post-trainees never ask for support. Even more troubling was the news that 74% of respondents reported having no access to support services. Burnout was suggested as a possible contributing factor,13
which may have an influence on emotional exhaustion, as trainees fear either discovery or being perceived as less clinically competent. 14
One method of creating support and destigmatizing burnout is by using group therapy. Balint training, an interventional method developed in the 1950s, is a form of group discussion aimed at helping physicians improve communication skills and overall doctor–patient relationships. During meetings, participants discuss cases, focus on clinical interactions, and practice interaction with a focus on empathy.15
The Journal of Clinical Oncology
detailed a study of a 2-year program in which 84 oncology fellows participated in Balint-like discussion groups. Participants reported improvements in their perspectives of themselves as physicians, their ability to deal with emotional clinical situations, and their comfort when discussing the stress of home at work.16
A second study in the Journal of Cancer Education outlined a bimonthly fellows’ luncheon where oncology and psychiatry attendings moderated discussions on topics such as breaking bad news, managing the depressed or angry patient, and complex family and cultural issues. Again, participating fellows reported high satisfaction with the sessions and improvements in their emotional well-being,17
suggesting that participating in group sessions can improve empathy and reduce symptoms of depersonalization and emotional exhaustion.
Training on End of Life
For the most part, the formal oncology curriculum focuses primarily on disease processes and therapeutics, not on clinical experiences, such as dealing with dying patients. Special effort is needed to openly discuss death, bereavement, maintaining empathy, and the inherent difficulty of EOL discussions. This effort is challenged, however, by our tendency to maintain a culture of resilience and toughness in “the war on cancer.” Often, acknowledging such issues comes only at the very end of life (if at all).
A study examining the relationship between fellow burnout and perceived preparedness for EOL care found that whereas 24.2% of fellow respondents reported high emotional exhaustion, lower emotional exhaustion scores were associated with explicit teaching about certain EOL topics. Fellows also reported less depersonalization and a higher sense of personal accomplishment if they had training on specific components of EOL care, such as explicit teaching on opioid rotation, instruction on when to refer a patient to hospice, and observations by an attending oncologist while leading a goals-of-care discussion. The authors concluded that although good EOL training may be associated with less burnout, additional focus on EOL aspects is needed.18
The study of the field of medical humanities in its various forms may help oncology trainees and other physicians to rekindle empathy and cope with burnout. The use of narrative medicine to help tell, listen to, and reflect on personal stories has been shown to improve clinicians’ understanding of their patients not merely as objects of care, but as unique and fellow humans.19
This was demonstrated through an educational mindful communication program that included narratives of meaningful clinical experiences, significantly increased empathy, and reduced symptoms of burnout among physician participants.20
Nevertheless, the majority of humanities-based medical education has focused on medical students and residents,21
and only rarely on specialty fellows.22
A pilot program focused on physician and patient narratives, which included medical, radiation, pediatric, and neuro-oncology trainees at the University of Rochester, resulted in high levels of attendance, positive qualitative feedback, and an eagerness among participants to continue the program. The authors encouraged further development of such programs to allow rekindling of the empathy that oncology trainees already bring with them and thus re-humanize the relationships between physicians and their patients.23
Physician, Heal Thyself
Of paramount importance, of course, is the concept of self-care. Individuals who pursue hobbies and engage in life outside of medicine are less likely to develop burnout and more likely to report a better quality of life. Taking just 1 day a week to do so can decrease the risk of emotional exhaustion and depersonalization. Other daily practices of self-care may include rewarding yourself with an early coffee break, taking a walk or a “time out” after a particularly challenging event, stopping at a window to take in nature, connecting with loved ones throughout the day, or practicing meditative breathing.24
Self-care is essential and has been shown to enable physicians to care for their patients in a sustainable way with greater compassion, sensitivity, effectiveness, and empathy.25
Ultimately, there are a variety of reasons why, at some point in our training and subsequent careers, our spirits and hearts will be challenged by the very work we chose to do. Recognizing contributing factors and engaging in thoughtful ways of processing them (whether through group discussion, reflective writing, or personal habits) can combat the attendant risks of an emotionally challenging career. Doing so will help each of us continue to serve in one of the most noble of professions; most importantly, we will continue to do that work well, in the interests of the people who need us the most.
- Bar-Sela G, Lulav-Grinwald D, Mitnik I. “Balint group” meetings for oncology residents as a tool to improve therapeutic communication skills and reduce burnout level. J Cancer Educ. 2012;27(4):786-789. doi: 10.1007/ s13187-012-0407-3.
- ACGME survey reveals concerning data on resident wellness. AMA Wire website. www.ama-assn.org/ama/ama-wire/post/acgme-survey-revealsconcerning- data-resident-wellness-1. Published June 8, 2015. Accessed October 14, 2015.
- Ramirez AJ, Graham J, Richards MA, et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer. 1995;71(6):1263-1269.
- Shanafelt T, Adjei A, Meyskens FL. When your favorite patient relapses: physician grief and well-being in the practice of oncology. J Clin Oncol. 2003;21(13):2616-2619.
- Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84(9):1182-1191. doi: 10.1097/ACM.0b013e3181b17e55.
- Shanafelt T, Dyrbye L. Oncologist burnout: causes, consequences, and responses. J Clin Oncol. 2012;30(11):1235-1241. doi: 10.1200/ JCO.2011.39.7380.
- Blanchard P, Truchot D, Albiges-Sauvin L, et al. Prevalence and causes of burnout amongst oncology residents: a comprehensive nationwide cross-sectional study. Eur J Cancer. 2010;46(15):2708-2715. doi: 10.1016/j.ejca.2010.05.014.
- Shanafelt TD, Raymond M, Horn L, et al. Oncology fellows’ career plans, expectations, and well-being: do fellows know what they are getting into? J Clin Oncol. 2014;32(27):2991-2997.
- Garrouste-Orgeas M, Perrin M, Soufir L, et al. The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but not burnout or safety culture. Intensive Care Med. 2015;41(2):273-284. doi: 10.1007/s00134-014-3601-4.
- West CP, Shanafelt TD, Kolars JC. Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents. JAMA. 2011;306(9):952-960. doi: 10.1001/jama.2011.1247.
- West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071-1078.
- West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302(12):1294-1300. doi: 10.1001/jama.2009.1389.
- Burnout in young oncologists: results of pan-European survey on the work conditions of young oncologists presented at the ESMO 2014 Congress. ESMO website. www.esmo.org/Career-Development/Young- Oncologists-Corner/Initiatives/Burnout-Project. Accessed October 14, 2015.
- Moutier C, Cornette M, Lehrmann J, et al. When residents need health care: stigma of the patient role. Acad Psychiatry. 2009;33(6):431-441. doi: 10.1176/appi.ap.33.6.431.
- Cataldo KP, Peeden K, Geesey ME, Dickerson L. Association between Balint training and physician empathy and work satisfaction. Fam Med. 2005;37(5):328-331.
- Sekeres MA, Chernoff M, Lynch TJ Jr, Kasendorf EI, Lasser DH, Greenberg DB. The impact of a physician awareness group and the first year of training on hematology-oncology fellows. J Clin Oncol. 2003;21(19):3676- 3682.
- Armstrong J, Lederberg M, Holland J. Fellows’ forum: a workshop on the stresses of being an oncologist. J Cancer Educ. 2004;19(2):88-90.
- Mougalian SS, Lessen DS, Levine RL, et al. Palliative care training and associations with burnout in oncology fellows. J Support Oncol. 2013;11(2):95-102.
- Dunn PM, Arnetz BB, Christensen JF, Homer L. Meeting the imperative to improve physician well-being: assessment of an innovative program. J Gen Intern Med. 2007;22(11):1544-1552.
- Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-1293. doi: 10.1001/jama.2009.1384.
- Shapiro J, Friedman M, Lie D. The resident as teacher of medical humanities. Med Educ. 2002;36(11):1099-1100.
- Gilewski T. The art of medicine: teaching oncology fellows about the end of life. Crit Rev Oncol Hematol. 2001;40(2):105-113.
- Khorana AA, Shayne M, Korones DN. Can literature enhance oncology training? A pilot humanities curriculum. J Clin Oncol. 2011;29(4):468- 471. doi: 101200/JCO.2010.33.3617.
- Quill TE, Williamson PR. Healthy approaches to physician stress. Arch Intern Med. 1990;150(9):1857-1861.
- Shanafelt TD, West C, Zhao X, et al. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med. 2005;20(7):559-564.