A recent survey by ASCO measuring postpandemic burnout among oncologists in the United States shows that professional satisfaction and work-life balance have significantly deteriorated over the past decade, with 59% of respondents reporting one or more symptoms of burnout, compared with 34% in 2013. Moreover, 57% of clinicians reported experiencing high levels of emotional exhaustion and agreed with the statement from the Maslach Burnout Inventory (MBI) Physician Well-Being Index that they “feel burned out from [their] work” weekly or more often, compared with 29% in 2013. When responding to a statement on their levels of depersonalization, 34% scored high on the MBI item indicating they “have become more callous” toward people weekly or more often since taking their job, compared with 13% in 2013.1
The survey was conducted in January and February 2023 and included responses from 410 United States–based oncologists. Demographically, the prevalence of burnout was higher among respondents with caregiving responsibilities compared with respondents without those responsibilities (65% vs 47%). Those younger than age 50 were more likely to have feelings of high levels of depersonalization compared with those aged 50 or older (39% vs 24%), and a greater percentage of non-White–identifying respondents reported high levels of emotional exhaustion compared with those identifying as White (63% vs 52%).
Additional survey findings showed that fewer 2023 respondents were satisfied with their life-work integration compared with those in 2013—24% vs 35%, respectively. When asked to identify factors associated with joy in their work, 63% cited “speaking with and advising patients” as the top factor. The two most often cited factors identified as those that may improve their work satisfaction were enhanced practice and administrative support (46%) and enhanced patient care support and staffing (44%).
The World Health Organization has defined burnout as a “syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed” and that is characterized by three symptoms: (1) feelings of energy depletion or exhaustion; (2) increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and (3) reduced professional efficacy.2
Supporting a Culture of Community in Oncology
“Prior to ASCO’s recent survey results, we only had anecdotal evidence of the extent of burnout among oncologists. Many of the stressors oncologists feel, including exceedingly long hours at work, rising patient volume, increasing electronic medical record administration, loss of autonomy, public mistrust, and political discord over evidence-based medicine, have been exacerbated following the COVID-19 pandemic,” said Fay J. Hlubocky, PhD, MA, FASCO, coauthor of ASCO’s 2023 professional well-being survey; Co-Chair of ASCO’s Clinician Well-Being Task Force; and Clinical Health Psychologist and Ethicist, Department of Medicine, Hematology-Oncology, at the University of Chicago Medicine, and the Maclean Center for Clinical Medical Ethics. “The information we have from this survey will help us advocate for oncologists when it comes to institutional interventions to support a culture of community in oncology.” (See “Reducing Physician Burnout and Improving Work and Personal Well-Being,” below.)
“Historically, we know that emotional exhaustion leads to the feelings of cynicism we are seeing in younger physicians.”— Fay J. Hlubocky, PhD
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In addition to the effects on oncologists’ physical and mental health, the consequences of burnout may take a toll on their financial well-being as well, according to a study by Dr. Hlubocky and her colleagues. They found that such effects may cost practices $4.6 billion per year in medical errors, staff turnover, physician shortages, lost revenue, and decreased patient satisfaction.3
The ASCO Post spoke with Dr. Hlubocky about ASCO’s survey results, the long-term effects of systemic racism on burnout, and how to improve work and life well-being.
Causes of Rising Rates of Burnout
Please talk about why oncologists are experiencing rising rates of burnout.
The reasons are many. Mounting clinical care responsibilities, increasing administrative and electronic medical record demands on clinical time and productivity, loss of autonomy over daily responsibilities, the evolving health-care landscape, ongoing cancer drug shortages, repeated exposure to death and dying, and dealing with insurers over prior authorization and reimbursement all compromise oncologists’ ability to treat patients and impact their sense of well-being.
In 2020, ASCO created the Clinician Well-Being Task Force to identify the major sources of burnout among oncology professionals and develop initiatives to address burnout and well-being. Some of the steps we recommend to help oncologists overcome feelings of burnout follow:
- Recognize the symptoms, such as overwhelming feelings of exhaustion, cynicism, and inefficacy, and how often they occur in themselves and their colleagues
- Learn resilience skills through increasing fitness routines, improving sleep habits, managing stress, and finding meaning in one’s work
- Build a supportive local culture of fellow oncologists and team members, and seek professional help in developing an action plan.4
Building Resilience Skills
Among the findings from the survey are that younger oncologists were more likely to have feelings of depersonalization compared with older physicians, and more non-White respondents reported having high levels of emotional exhaustion compared with their White counterparts. Were you surprised by these results?
Sadly, this was not a surprise. Research has consistently shown a generational divide among oncologists, with younger, early-career oncologists at greater risk of experiencing occupational stress and developing burnout than their older colleagues, primarily because of unaddressed emotional exhaustion.
A feeling of depersonalization, defined as a lack of empathy for or a negative attitude toward patients, becomes a coping mechanism for physicians exhausted from their clinical workload. Younger oncologists, such as early-career practitioners and fellows, have reported that they never expected to start their career in oncology during a global pandemic, having to worry about contagion and how the coronavirus would affect their immunocompromised patients. I do not think we have adequately appreciated how those early burdens and the pandemic-related emotional and physical health stressors impacted oncologists’ ability to practice with limited resources and increased patient volume.
Furthermore, research tells us that feelings of depersonalization and burnout can be addressed over time if physicians tap into building resilience skills, for example, by reinforcing their goals and reasons for deciding on a career in medicine, which helps to rebuild empathy. This is probably one reason why fewer older physicians reported having high levels of depersonalization in the ASCO survey. They have had more time in their career to learn and build resilience skills, even in the absence of institutional support.
Cascading Effect of Systemic Racism
Why are so many minority physicians experiencing greater feelings of emotional exhaustion?
Emotional exhaustion is a core symptom of burnout and is likely the result of the unique experiences that for many physicians started in medical school. Historically, we know that emotional exhaustion leads to the feelings of cynicism we are seeing in younger physicians.
For oncologists from underrepresented groups, we know emotional exhaustion and burnout can be caused by various factors, such as systemic and structural institutional racism, racial discrimination, and unconscious bias experienced early in training and in clinical life, including interactions with colleagues, patients, and patients’ families. Emotional exhaustion can also arise as a result of inequities in pay and career advancement. They are all potential reasons why we are seeing higher rates of emotional exhaustion in our survey data.
Other Contributors to Burnout
What can institutions do to provide relief for oncologists, especially for women and non-White physicians?
We know from prior research in other subspecialties that physicians from underrepresented groups and female physicians consistently report greater caseloads and spend more time devoted to administrating patients’ electronic health records and more time with patients per visit. These factors, as well as the aforementioned systemic and structural racism, institutional and gender biases, and inequities in compensation, put both groups at greater risk for burnout. In addition, childcare and eldercare responsibilities outside of work contribute to decreased job fulfillment and job satisfaction, and with satisfaction in minority oncologists’ overall work-life balance.
To address the symptoms of burnout, research tells us that we have to eliminate the racial and gender biases and harassment that both underrepresented and female physicians experience in medicine. Institutions have a responsibility to assess burnout among their staff and develop a blueprint to address the problem, including instituting flexible work hours and providing family and medical leave options that do not negatively impact physicians’ career trajectory. Institutions also need to allocate resources to ensure the success of women and minority physicians in their career development that prioritizes their physical and mental health and fosters a culture of learning, building resiliency and trust in the system to address harassment and microaggressions.
We need more research tailored toward the field of oncology to provide greater insight into the causes of institutional inequities. Any tailored institutional interventions would help reduce burnout and improve clinician well-being. Such measures could also aid in promoting workforce diversity and preventing workforce attrition for both underrepresented and female physicians.
Improving Work and Personal Well-Being
Please talk about some interventions and policies institutions can implement to enhance support for administrative and patient care tasks to mitigate burnout and improve oncologists’ overall well-being.
Both community practices and academic medical centers have initiated interventions in an attempt to mitigate physician burnout. In many instances, their efforts are individual and depend on the subspecialties, such as medical vs surgical oncology vs independent oncology practice type; practice location; and organizational environment. But in all cases, interventions are designed to address the increasing clinical workload oncologists are experiencing.
Some of the most effective interventions to reduce burnout and improve quality cancer care include providing flexible work schedules and reducing clinician time spent on administrative tasks; assessing burnout frequently in clinicians; proactively engaging organizational leaders and physicians in collaborative action planning; optimizing the clinical practice environment and institutional culture; implementing change within the practice and institution for optimal evidence-based cancer care delivery; and moving away from volume-based care to value-based cancer care.
DISCLOSURE: Dr. Hlubocky reported no conflicts of interest.
REFERENCES
1. Schenkel C, Levit LA, Kirkwood MK, et al: The state of professional well-being and satisfaction among US oncologists. JCO Oncol Pract 19(suppl 11):1. 2023.
2. World Health Organization: Burn-out an ‘occupational phenomenon’: International Classification of Diseases. Available at www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases. Accessed March 20, 2024.
3. Hlubocky FJ, Shanafelt TD, Back AL, et al: Creating a blueprint of well-being in oncology: An approach for addressing burnout from ASCO’s Clinician Well-Being Taskforce. Am Soc Clin Oncol Educ Book 41:e339-e353, 2021.
4. Hlubocky FJ: Attending to oncology well-being. JCO Oncol Pract 18:541-542, 2022.
REDUCING PHYSICIAN BURNOUT AND IMPROVING WORK AND PERSONAL WELL-BEING
By Jo Cavallo
According to ASCO’s Oncology Clinician Well-Being Task Force, clinician well-being is an integrative concept that characterizes quality of life, encompassing work- and personal health–related environmental, organizational, and psychosocial factors. As a recent study by the Task Force made clear, cancer care clinicians may be at particular risk of occupational burnout, which can have a major impact on well-being.
Organizational interventions can play a role in preventing and reducing burnout by providing flexible work schedules and reducing clinician time spent on administrative tasks; assessing burnout frequently in clinicians; proactively engaging organizational leaders and physicians in collaborative action planning; and optimizing the clinical practice environment and institutional culture. However, according to Fay J. Hlubocky, PhD, MA, FASCO, coauthor of ASCO’s 2023 professional well-being survey, oncologists have to be proactive in their own well-being. Dr. Hlubocky is Co-Chair of ASCO’s Clinician Well-Being Task Force and Clinical Health Psychologist and Ethicist, Department of Medicine, Hematology-Oncology, at the University of Chicago Medicine and the Maclean Center for Clinical Medical Ethics.
“I always tell physicians to empower themselves to improve their well-being by becoming their own change agent in their institution or practice. They can promote change in the oncology practice environment, public policies, and laws regarding practice issues (such as cancer drug shortages and insurance prior authorizations) by participating in ASCO’s state and regional affiliate program (https://old-prod.asco.org/get-involved/advocacy/state-regional-affiliates),” said Dr. Hlubocky. “And although addressing burnout is an organizational responsibility, you should protect yourself and prioritize your well-being by practicing self-care and getting enough sleep, exercise, and good nutrition, which are effective critical tools to help cope with workplace stressors. And please do seek peer and professional support at the first signs of burnout. Your well-being has never been more important.”
Recognizing the Symptoms of Burnout
The first step in reducing burnout is recognizing the symptoms and how frequently they occur. According to a study by Dr. Hlubocky and her colleagues, if clinicians are experiencing irritability, impatience, exasperation, or feeling burdened by work weekly or more often, it may be time to seek out a professional for an assessment and the creation of an action plan.1
Other signs of burnout syndrome include physical and emotional exhaustion; chronic fatigue; cardiovascular issues; insomnia; symptoms of affective and behavioral distress, such as anger, irritability, depression, and anxiety; cynicism and depersonalization; pessimism; isolation; demoralization; detachment; low sense of personal accomplishment; feelings of inefficacy; decreased productivity; and overall dissatisfaction in work-life balance.
Taking Control
After recognizing the symptoms of burnout and seeking out professional advice, the following interventions may also help to reduce burnout1:
- Employ resilience strategies for wellness—for example, building habits that ensure adequate amounts of sleep and good fitness levels.
- Use techniques derived from cognitive-behavioral psychotherapy to reduce stress.
- Practice mindfulness strategies, such as meditation and yoga, to bring full attention to the present moment.
- Reconnect with your purpose as a physician through reflective practices that help you recall meaningful experiences and to draw guidance from them for the future.
- Connect with colleagues on a personal level to address the isolation many clinicians feel at work.
- Rebuild a local culture of oncology clinicians through advocacy that ensures the best care for patients.
REFERENCE
1. Hlubocky FJ, Back AL, Shanafelt TD: Addressing burnout in oncology: Why cancer care clinicians are at risk, what individuals can do, and how organizations can respond. Am Soc Clin Oncol Educ Book 35:271-279, 2016.
