Stress Among Medical Oncologists: The Phenomenon of Burnout and a Call to Action

The phenomenon of burnout can be described as frustration or a sense of failure in one's profession. It has been well chronicled in the lay press and seems particularly indigenous to persons in high-stress occupations, such as emergency department physicians, air traffic controllers, law enforcement personnel, and fire fighters. A recent survey in the Journal of Clinical Oncology documented the magnitude of the problem of burnout among medical oncologists—approximately 60% experience this phenomenon. Persons who struggle with the issue of disillusionment transform from caring individuals to apathetic ones; they replace commitment and compassion for aloofness and emotional indifference; and they exchange openness and warmth for a protective, defensive, and self-serving posture. Trust and faith become eroded by suspicion; optimism and enthusiasm are diluted by feelings of cynicism and sarcasm.

These distressing feelings and attitudes are not limited to only some members of the oncologic community but are certainly prevalent among physicians as a group.^{,  ,}  Casual conversations in hallways during major meetings or during coffee breaks are often a more revealing barometer of satisfaction than are published surveys. Chemical dependence (especially alcoholism), suicide, and interpersonal discord have been well documented among the ranks of physicians. A recent study found a higher consumption of alcohol among physicians than among the general population, and heavy drinking seems associated with burnout. Two surveys have documented that 40 to 50% of emergency department physicians and infectious disease subspecialists experience disproportionate levels of stress, depression, and emotional exhaustion.²³ The frequency of alcoholism in the medical profession is a problem. The palpable discontent and unhappiness among many physicians cannot prudently be ignored. As we enter an era of increasingly burdensome fiscal constraints and of bureaucratic intrusions into the delivery of health care, these issues will continue to escalate, and professional morale will deteriorate further. Financial, administrative, and legal issues, of which clinicians have minimal control, are clear stressors that cannot be discounted.

During the past 5 to 10 years, a general perception of unhappiness has existed among the “rank and file” of the oncologic community; however, minimal efforts had been invested to verify this discontent. In a fascinating study, questionnaires were mailed to 1,000 randomly selected subscribers of the Journal of Clinical Oncology. Respondents were asked to describe their expectations and training and frequency of burnout in their professional activities. The causes of burnout and suggestions for alleviation were also addressed. The questionnaire included both multiple-choice and open-ended questions. The surprisingly high rate of completion of the questionnaire (60%) may be evidence of the deep emotional chord that was struck by this study. Of the responses, 85% were received in the first 2 weeks. Of special importance is that most respondents were active, practicing clinicians who devoted a median of 70 to 79% of their time to patient care. Only 1 to 9% of them were involved predominantly in clinical or laboratory research.

Overall, 56% of respondents reported that they felt burnt-out. The largest subgroup who experienced this phenomenon was the 60% (N = 219) who completed their training between 1970 and 1979. The correlation between the frequency of burnout and the geographic location was not significant between urban and rural practitioners. In contrast, institution- or university-based oncologists reported a 47% burnout rate in comparison with a 66% rate for practitioners in oncology and in internal medicine (P = 0.0003). Undoubtedly, this difference reflects, at least in part, more intense clinical responsibilities.

Several possible explanations exist for the disturbing finding of burnout among medical oncologists. The most consistent factor provoking burnout was related to palliative or symptomatic-supportive care. Some respondents (56%) were frustrated and had a sense of failure. This percentage correlated directly with hours of patient care.

The conclusions associated with the survey of randomly selected oncologists are subjective and provocative. The targeted thrust of most oncology programs and the areas that receive greatest emphasis are the active treatment of patients with use of complex multimodality programs that involve radiation therapy, chemotherapy, biologic-response modifiers, and surgical intervention. The overwhelming proportion of these patients have diseases that are incurable, and such patients may receive only a limited amount of active anticancer therapy. Their remaining duration of survival involves symptomatic and supportive measures. Most oncology programs should probably reorient the focus so that emphasis on palliative care is greater because this type of treatment will consume most of the oncologist's active practicing day. Oncologists must recognize the absolute inevitability of an emotional “meltdown” if they perceive that their primary role is to eradicate malignant disease. Currently, the possibility of outright cure of disseminated disease applies to a few patients with selected neoplasms, such as germ cell tumors, lymphoproliferative disorders, and some breast cancers. The art and science of orchestrating and participating in investigational clinical trials and an appreciation of the statistical nuances of new drag developments are obviously important during oncologic training. A renewed focus for the management of patients for whom active treatment is no longer appropriate because of clinical deterioration and lack of effective therapies might be helpful.

Another factor in the phenomenon of burnout may be that discovering the “magic potion,” perhaps more a concern of the basic researcher than the pragmatic clinician, has been a frustratingly elusive goal. Undoubtedly, gains in managing patients with malignant disease have been substantial. For most patients with advanced cancer, the quality of life is immeasurably better than it was a decade ago, especially relative to pain management and symptomatic care. Nonetheless, a chasm seems to exist between basic scientists involved in the interesting and newsworthy developments and medical oncologists struggling with the practical realities of clinical medicine and the expectations, sometimes unrealistic, of patients and families.

The theme of burnout has been expanded. Several topics have been discussed and methods have been advocated to shore up and salvage the “frontline troops”—clinical oncologists—in the war against cancer.^, 

Despite the obvious challenges and the depressing aspects of an oncologic practice, there are rewards and satisfaction that few other practitioners can appreciate. The tremendous courage of most patients with cancer and the dogged strength of family members to push on despite spirit-draining experiences are particularly remarkable. Oncologists have the privilege to participate in these struggles. The abilities to care for dying patients, however, are only as good as oncologists' abilities to care for themselves.