Mar 28, 2011
By Virginia Anderson, Senior Writer/Editor
Nearly everyone has an occasional “case of the Mondays.” But if you dread going to the office every day, you may be suffering from burnout.
Burnout differs from depression in that it particularly affects an individual’s feelings toward his or her professional activities. The Mayo Clinic describes burnout as “a state of physical, emotional, or mental exhaustion combined with doubts about your competence and the value of your work,” and notes that those in “helping professions” such as health care may be especially prone to burnout.1
A broad definition, to be certain.
“While it may be possible to define burnout, the real challenge lies in its prevention,” said Michael Goldstein, MD, of Beth Israel Deaconess Medical Center.
As Chair of ASCO’s Workforce Advisory Group, Dr. Goldstein considers the effect of burnout and its precursor, physician dissatisfaction, on the oncology workforce, which is already under the pressure of an anticipated shortage of oncology professionals over the next decade. “The extreme result of burnout is exhibited by physicians who actually leave the profession. While most leave as a result of job dissatisfaction, some have frank depression, and a small subset turns to drugs and alcohol,” he said. He also emphasized that burnout is not limited to physicians but can affect all members of the oncology care team.
Although burnout is not codified as a medical condition in the current Diagnostic and Statistical Manual of Mental Disorders (DSM), it is prevalent enough in the oncology community that Carolyn D. Runowicz, MD, of the University of Connecticut Health Center, included “addressing oncologic burnout” among her priorities during her term on the ASCO Board of Directors, which will commence at the 2011 ASCO Annual Meeting.
“I’m a gynecologic oncologist and a surgeon, but it is clear that burnout is not unique to any group,” she said. “It’s a problem that we all face, and that’s a reflection of the change in medicine with respect to hours worked, reimbursement issues, increasing regulation, and documentation.”
The documentation burden
“Medicine has changed a lot since I first started practicing,” Dr. Runowicz said. “The frustration of having to document everything you’ve done—the dictum that if you didn’t document it, it wasn’t done—didn’t exist years ago. One of the documentation jokes is that you can take care of a patient in 20 minutes but the paperwork takes 40 minutes. Documentation has become an increasingly important part of our responsibilities and adds to the hours of work that we do, and in my opinion, it’s the least rewarding aspect of everything we do.”
In a 2006 study on workforce issues commissioned by ASCO, a survey of 4,000 member oncologists supported Dr. Runowicz’s assertion: 32% of respondents indicated feeling burned out at least once a week, and specifically noted the frustration of administrative requirements in their comments.2
“The list of activities that oncologists found the most onerous was not what you’d expect—it was not having a patient die, it was not loss, it was not working long hours or working nights and weekends. That’s what they signed up for when they became oncologists,” said Dr. Goldstein. “What they found most distressing was fulfilling what many consider senseless regulations, especially the need for excessive documentation which did not contribute to the well-being of the patient.”
ASCO is advocating on behalf of burdened oncologists for measures to reduce administrative requirements, such as simplifying payment mechanisms, limiting redundant documentation efforts, and optimizing data collection during clinical research (see sidebar on page 32 for more information on these programs).
“Oncologists are very invested in delivering up-to-date, humane care that satisfies everyone involved. If the burdens of one’s profession become overwhelming, for any reason including overregulation, that generates the feelings associated with burnout,” Dr. Goldstein said.
New generation, new expectations
While burnout may be pervasive among medical professionals today, Dr. Goldstein and Dr. Runowicz both believe that the new generation of oncologists will experience less work-related dissatisfaction. First, young oncologists have always practiced in an era of documentation and regulatory requirements and may view it as an integral part of practice rather than an additional burden. Second, they have made work/life balance a priority. In a 2005 survey of graduating fellows, 60% of those surveyed rated work/life balance as “extremely important” in determining their post-training plans, while only 20% rated salary/pay as extremely important.3
“I think the younger generation of physicians will probably suffer less burnout because they are expressing what my generation didn’t—a need to balance their professional and personal lives. The young people going into practice today (academic or community) value family and vacation time, and are generally not interested in working hugely long hours as some physicians did in prior generations. It’s a motivating force in their job selection, and I think it’s a healthy one,” Dr. Goldstein said. “It should also be pointed out that the workplace environment may contribute to burnout. You may love your work but if you feel undervalued or have excessive demands on your time, you may also be at the risk for burnout,” he added.
Dr. Runowicz believes that senior physicians should support, not discourage, this mindset among their staff, and perhaps embrace it themselves. “Those of us who are senior need to recognize that times have changed and the 24/7 ‘dedicated’ physician/surgeon is not a healthy model going forward. We need to identify that there are personal issues, including family, friends, and outside activities, as well as professional issues that we need to do a good job of attending to. That has to be promoted among our young people and not looked at disparagingly,” she said. “That’s going to require a sea change. We have to think in new paradigms and make sure that our young trainees get quality time away from patients, practice, and medical issues.”
There are few formal resources for medical professionals who feel burned out, so oncologists must be advocates for their own well-being. Some of the following strategies may help prevent or mitigate feelings of burnout:
- Lean on a mentor, supervisor, or colleague for support. “Part of my job as director of our cancer center is psychological support. I often serve as a sounding board for a lot of the junior people,” Dr. Runowicz said. “My door is always open—people will pop in, sit down, and start talking to me about their frustrations, and I listen. If they are working too hard, I emphasize to them to hand things off. You don’t have to do every appendectomy that comes your way when you’re a surgical oncologist.”
- Take time for activities you enjoy. “Whatever gives one feelings of personal satisfaction or personal growth will help alleviate burnout. One of my colleagues handles stress by running 10 miles. For myself, hobbies and a planned vacation or trip have always helped. However, it is not just time away that helps restore vitality and enjoyment. Having a diverse work life, which may include research, teaching, administration, and involvement in professional or advocacy activities, buffers against early burnout,” said Dr. Goldstein.
- Make your physical health a priority. “I learned firsthand that you can’t be your own doctor,” Dr. Runowicz said. “I tried to be my own doctor and I ended up in an intensive care unit for two weeks. I almost died of heart failure because I ignored my symptoms.
After I had breast cancer in 1992, I developed an exercise and diet routine that I’m religious about. Before that, I just thought I was invincible, but I’ve learned on more than one occasion that invincibility is not one of my characteristics. Taking care of yourself has to be a priority.”
- Don’t be afraid to seek counseling, even if you want it to remain private. “Many people find it extremely difficult to admit to themselves or colleagues that they’re having problems. If maintaining privacy is an issue, it is better to seek help outside one’s own institution than to forego counseling entirely,” Dr. Goldstein noted. Many employers also offer confidential employee assistance programs that cover sessions with a therapist or counselor.
- Use your vacation days—you’ve earned them. “Oftentimes physician burnout is piggybacked on fatigue. You lose your way: you don’t think you’re doing a good job, it’s hard to get to work in the morning, and you’re just exhausted. Vacations and time away from work are important to recharge,” Dr. Runowicz said.
- If you won’t do it for yourself, do it for your patients. “A physician who is happy at work communicates that to patients. The burned-out physician may be able to deliver appropriate technical care or order the right doses of chemotherapy, but the psychosocial interaction between physician and patient, especially in oncology, will suffer if the physician is burned out,” Dr. Goldstein said.
ASCO Addresses Administrative Burden
One goal of ASCO’s government relations and advocacy work is to reduce the administrative burden facing oncology clinicians and researchers. ASCO has developed several initiatives in the past year to improve the day-to-day practice for oncologists, including ways to ease the ever-growing administrative burden.
Relations with payers
The amount spent on administrative overhead by both providers and payers is unacceptable—and unsustainable. ASCO held the first Provider-Payer Initiative meeting in fall 2010 in order to establish productive dialogue between oncologists and the payer community; enhance shared understanding of the challenges each stakeholder experiences; improve the quality, safety, and affordability of care; and promote ongoing informational exchanges. Reductions in administrative overhead could potentially be achieved through unification and simplification of payment mechanisms, as well as replacement of pre-authorization programs by quality programs.
Payer recognition of QOPI®support
ASCO’s Quality Oncology Practice Initiative (QOPI®) promotes excellence in cancer care by helping oncologists create a culture of self-examination and improvement. To reduce redundancy of data collection and measurement, QOPI participants can request that ASCO send verification of QOPI participation to applicable health plans that participate in the program. ASCO is also in discussions with regulators and policymakers to have QOPI participation recognized by Medicare.
FDA Risk Evaluation and Mitigation Strategies (REMS)
Risk Evaluation and Mitigation Strategies (REMS) programs, which are intended to address drug safety concerns, can impose significant administrative burden on practices without equitably improving patient safety. ASCO is concerned about this additional strain and is identifying alternate approaches that will both effectively address safety concerns and avoid unnecessary paperwork.
Data optimization for research
Although much is known about the safety of an anticancer agent at the time of initial marketing approval, sponsors customarily collect comprehensive safety data for studies that support supplemental indications. This adds significant cost and complexity to the study and may not provide useful new information. ASCO conducted an analysis of the amount of safety and concomitant medication data collected for supplemental application to determine a more efficient approach for collection. Analysis revealed that limiting and focusing data collection on signals that cause changes in treatment captures important safety issues while minimizing administrative strain. ASCO submitted these recommendations to the FDA and requested that the agency issue guidance on the topic.
For more information on these initiatives, please contact ASCO’s Cancer Policy and Clinical Affairs Department at firstname.lastname@example.org.
ASCO Resources on Physician Burnout
- Mayo Clinic. Job burnout: Spotting it—and taking action. Accessible at mayoclinic.com/health/burnout/WL00062.
- Forecasting the Supply of and Demand for Oncologists: A Report to the American Society of Clinical Oncology (ASCO) from the AAMC Center for Workforce Studies. 2007:49-50. To download, visit asco.org, select “Practice & Guidelines,” then “Workforce Initiatives.”
- Ibid. Pages 38-39.