JCO Exclusive: Oncology Fellows Underestimate Their Workload—Which May Lead to Burnout

Sep 08, 2014

By Shira Klapper, Senior Writer/Editor

According to a new study in the Journal of Clinical Oncology (JCO), “Oncology Fellows’ Career Plans, Expectations, and Well-Being: Do Fellows Know What They Are Getting Into?” published online, ahead of print, July 21, the number of hours oncology fellows expect to work is significantly lower than the amount of hours practicing oncologists actually work.

Study first author, Tait D. Shanafelt, MD, summed up the findings this way: “Fellows expect something different from what their experience actually is. And that could be part of the dissatisfaction, or ‘burnout,’ experienced by some oncologists in practice.”

The study, which was supported, in part, by the Conquer Cancer Foundation (CCF) of the American Society of Clinical Oncology (ASCO), found that fellows underestimated the number of nights they would need to be on call, the number of hours they would need to devote to work tasks when at home, and the number of outpatients seen in clinic per week. In addition, fellows overestimated the number of hours they would have available to devote to reading journals and keeping up with current research.

A 97% response rate

A major advantage of this JCO study was having ASCO as a co-sponsor—an affiliation that enabled the researchers to distribute their questionnaires at the time of the 2013 Medical Oncology In-Training Examination (MedOnc ITE). The test is developed and administered by ASCO to measure fellows’ medical oncology knowledge. Of the 1,637 oncology fellows in the United States in 2013, 89.3% took the exam, and of those, 97.9% completed the questionnaire, a remarkably high response rate for this kind of study.

The questionnaire asked fellows to make projections about their future practices in terms of the number of patients they expected to see per week, the amount of hours they would devote to administrative tasks, the amount of work they would have to take home and other variables that measure work hours. The questionnaire also asked fellows to assess their career satisfaction, quality of life, and level of burnout.

Comparative data from practicing oncologists was gathered from a simultaneous national study also sponsored by ASCO.

The researchers were interested in three main outcomes: Whether burnout and quality of life improved after fellowship, whether ITE scores were related to certain demographic and quality of life variables, and whether fellows’ expectations differed from the reality experienced by practicing oncologists.

Expectations versus reality

Fellows were categorized by whether they intended to enter academic or private practice, with different expectations found for each group. Fellows intending to go into academic practice underestimated the amount of time spent weekly on administrative tasks by more than five hours. They underestimated time spent at home working on professional tasks by more than two hours.

The greatest discrepancy however, was seen among fellows intending to go into private practice, in terms of the number of patients they expected to see in clinic per week. Fellows projected they would see an average of 65.9 patients per week; in reality, according to the data from practicing oncologists, that number is closer to 74.2 patients.

Does burnout get better after fellowship?

Tait D. Shanafelt, MD   

In the study, fellows and doctors reported the same 40% burnout rate, with practicing oncologists reporting an even higher burnout rate than third-year fellows. This finding is explored more in depth in the JCO podcast, “Why are Fellows’ Burnout Rates as High as Those of Practicing Oncologists?”

The study also showed that fatigue and quality of life do indeed improve once oncologists start practicing—but career satisfaction and work-life balance decline.

“I think there’s a common misconception during the training years of both residency and fellowship that ‘things will get better after I’m done with training,’” said Dr. Shanafelt. “What we see is that, although some dimensions of quality of life may improve as fellows entered practice, burnout persists and other challenges, such as difficulty integrating personal and professional life, may increase.”

Since this survey was part of the post ITE survey, the researchers were also able to look at connections between ITE scores and other study variables. The study showed that as fellows’ burnout levels went up, ITE scores went down. This finding indicates that burnout might potentially impact fellows’ ability—or motivation—to take in new information.

Better attention to work-life balance needed

Dr. Shanafelt said that to help fellows avoid burnout, the problem needs to be addressed on multiple levels, including helping individual fellows develop realistic expectations about the oncology profession, examining the structure of fellowship training, and working to improve broader health care policy.

“During fellowship, I think the goals are not only to help develop competent clinicians and provide fellows insight into what their future careers are going to be like, but to equip them with skills to address the challenges they will face once they’re in practice so that they do not burnout or leave the field,” said Dr. Shanafelt.

According to Dr. Shanafelt, a good deal of the change will have to come from initiatives on the practice and health policy levels.

“There are parts of the problem that are very much dependent on characteristics of the work environment, such as the ways in which practices are structured, patient volume expectations, call schedules, night coverage, the amount of autonomy a physician has, and the way we structure teams,” said Dr. Shanafelt. “And then there are factors that are even bigger than an individual practice, related to national patterns of reimbursement, inefficiencies in the care delivery system, and insurance pre-approvals and bureaucracy. These national factors influence the way we practice oncology and practice medicine. “

Tait D. Shanafelt, MD, is a hematologist, the Director of the Mayo Clinic Department of Medicine Program on Physician Well-being, a Professor of medical education, and a Professor of Medicine at the Mayo Clinic, in Rochester, Minnesota.


This JCO study was funded in part by the Conquer Cancer Foundation of ASCO. To learn more about CCF funding opportunities or to donate, visit conquercancerfoundation.org.





Click here to read the abstract.





Click here to read the PDF.


Shanafelt TD, Raymond M, Horn L. Oncology fellows’ career plans, expectations, and well-being: do fellows know what they are getting into? J Clin Oncol. Published online 7.21.2014.

The Exclusive Coverage series on ASCO.org highlights selected research from JCO and JOP with additional perspective provided by the lead or corresponding author.






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