Burnout is widespread in oncology, occurring in around 25% to 35% of medical oncologists, 28% to 36% of surgical oncologists, and 28% of radiation oncologists. In his previous interview with i3 Health, Daniel C. McFarland, DO, a medical oncologist and psychiatrist at Memorial Sloan Kettering Cancer Center in New York City, discussed what can be done about the high rates of suicide among physicians and the particularly high rates of depression among oncologists. In this second installment, he discusses burnout, which can go hand in hand with depression. Dr. McFarland and colleagues addressed the issues of burnout and depression among oncologists in a recent publication of the American Society of Clinical Oncology (ASCO), and Dr. McFarland presented on these topics at this year's ASCO Annual Meeting.
What factors contribute to burnout, both among physicians in general and among oncologists in particular?
The burnout issue has multiple factors, but perhaps the biggest of these is a worker/workplace mismatch. Not much has changed in terms of the workers, but there have certainly been recent changes in the workplace, including more administrative burdens such as the use of electronic medical records (EMRs) and electronic health records (EHRs), as well as pressures to see more and more patients. Therefore, physicians are actually spending less time with each individual patient. Spending time with patients is what makes doctoring meaningful. When you're undermining that, people get burnt out, and their sense of purpose is diminished.
All of these problems are essentially on the administrative end, so understanding how to make the system work in a better way for the people that are involved is important. For the burnout picture, I look at both the systemic factors, which are primarily about the administrative burden, and then at the individual factors.
I won't go into many of the individual factors because I don't think they should be highlighted as much: it should not be a matter of self-blame, which is often how talk about individual interventions gets interpreted. The kind of talk where we start saying, "Oh, if you're this kind of person, then you're more at risk for burnout" should be avoided, but there are certain personality traits that place doctors more at risk. Ironically, the people who are most driven, who are willing to work longer hours, and who are willing to take on more and more and more end up being really good physicians who are hypervigilant and are great at what they do, but they're not as good at setting limits and saying no. Those two things can go hand in hand.
All of the medical subspecialties are experiencing burnout at higher rates. Some specialties have higher rates of burnout than others, however, so that has something to do with the different types of work. As I mentioned previously in my discussion of oncologists and depression, oncologists can experience secondary trauma, or compassion fatigue, when they feel the stress of every patient and every family member. While it can be rewarding for us to be there for our patients during what is for them a very vulnerable time, it can also lead to burnout.
What can hospitals and cancer clinics do to help alleviate feelings of stress and burnout among oncologists and other physicians working with patients with cancer?
It has to be a multifaceted approach. Again, I think it's very important not to blame the workers for feeling this way. That should go without saying, but it's important to highlight because a lot of people feel like they're being blamed, that if they experience burnout, it's their own fault. The first thing to do is just to frame the burnout issue in a way that lets the doctors know that it's not their fault.
I hope that organizations are really starting to take this problem seriously. I think they're getting that message. The problems are variable, so the solution has to be variable as well. Every institution has its own specific culture and its own specific workflow patterns. I look at this as a quality initiative, a process that has to be specific to the environment, and it takes a lot of collaboration between the workers and the administrators to come up with a good plan. I think the key is that the physicians need to be involved in whatever kinds of initiatives are going to take place to address burnout.
I always cite the study by Dunn and colleagues (2007), which I think was just genius. They had a group of doctors at various practices under the same umbrella company monitor their own burnout and come up with their own plans for addressing it. It seems simple enough, but that's exactly what is needed. Part of burnout is feeling out of control, feeling like you're ineffective. When you do something to put the clinician back into control, that in and of itself is actually addressing burnout, so that would be one example of what can be done.
The other thing that organizations can do is to really examine the nitty-gritty workflow issues that exist. Clinicians have all kinds of ideas about what inefficiencies are slowing them down. A lot of this goes back to the EHRs. It is essential for the institution to work with their tech support departments to solve these small things, which can make a really big difference. Physicians end up spending a lot of time just clicking all these buttons. You get this sort of fatigue from doing these non-cognitive sorts of things, and when you do them every day, you start thinking that you didn't go to medical school to click buttons. To click buttons—really, that's the implication. You went to medical school, you've got decades of training under your belt, and here you are talking to insurance companies, explaining basic things—the insurance companies intentionally set things up that way to slow you down so that your request is forgotten or neglected—and clicking buttons in your EHR. Then, 5% of your time is spent actually making real decisions. It's that mismatch which is bad.
There was a great op-ed in The New York Times by Danielle Ofri, MD, that made this point, summarized poignantly in the article's title: "The Business of Healthcare Depends on Exploiting Doctors and Nurses." Since the training of doctors and nurses requires them to be altruistic, we are taught to be self-sacrificing and always go the extra mile as part of being good and doing our duty without commensurate compensation for the time that is required, as would be the case in other businesses.
One possible solution to this issue, one which institutions are starting to implement, is to use scribes, people that take notes for physicians. When an organization does something like that, it sends the message that they really take this issue very seriously. That is one of a whole multitude of things that can be done.
There is an element that as doctors, we need to take care of ourselves. It's like we have to meet each other halfway. Wellness should just be a part of being a physician. We're getting to know more and more, and at this point, we certainly know a lot about what it takes to be well. At the same time, I would just highlight that yoga, mindfulness-based stress reduction, and all of these other things that can be done by an individual don't really mean anything if your workflow is totally inefficient.
For oncologists in particular, a sense of community is really important, and that's something that organizations can encourage in an official capacity. We're actually starting to do this at Memorial Sloan Kettering, just providing time to be with colleagues. At Mayo Clinic, I believe, they actually pay for the doctors to go out to lunch with each other. It seems almost silly, but it's not. We're so busy that we really don't have the time to just have small talk and relax with each other. That is key, especially when you're in the stressful situation of dealing with really sick patients who are dying. Developing this sense of community in oncology is crucial.
About Dr. McFarland
Daniel C. McFarland, DO, is a medical oncologist and psychiatrist at Memorial Sloan Kettering Cancer Center. He completed a combined residency program in internal medicine and psychiatry at Rush University Medical Center in Chicago followed by a fellowship in medical oncology/hematology at the Icahn School of Medicine at Mount Sinai in New York City.
For More Information
Dunn PM, Arnetz BB, Christensen JF & Homer L (2007). Meeting the imperative to improve physician well-being: assessment of an innovative program. J Gen Intern Med, 22(11):1544-1552. DOI:10.1007/s11606-007-0363-5