Where There’s Smoke: Are Oncology Fellows in Danger of Burnout?

Morganna Freeman, DO, FACP
Published: Sunday, Oct 02, 2016
Morganna Freeman, DO, FACP

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
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