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Optimizing Work–Life Experiences and Avoiding Burnout in Oncology

September 2015, Vol 5, No 6

Burnout among oncology providers hinders thriving and development at the individual level and delivery of value at the system level, said 2 experts during a practice management session at the 2015 American Society of Clinical Oncology annual meeting.

Intervention is needed at both levels to reverse a growing tide of burnout, said Anthony L. Back, MD, Professor of Medical Oncology at the University of Washington and Fred Hutchinson Cancer Center in Seattle. Healthcare systems must move on from a “diagnose and fix” strategy to one of proactive burnout prevention.

“Burnout matters,” said Dr Back. “At the level of the individual, it’s about our well-being, as clinicians and healers, and about the well-being of our patients. There is data showing burnout is associated with suboptimal patient care, medical errors, and low patient satisfaction. It all culminates in feeling like you’re not the doctor you wanted to be or set out to be.”

“For systems, burnout poses major workforce issues. As it turns out, we oncologists and oncology nurses are extremely expensive to replace. A lot of turnover on our part is not good for our health systems or our patients. In this era of looming workforce shortages, this is something we need to think about at the level of the system,” Dr Back said.

Burnout Criteria

Once considered a workplace phenomenon without formal clinical parameters, burnout has acquired a clinically recognized definition associated with specific manifestations. According to Dr Back, burnout is a “clinical syndrome of mental distress that includes frustration, powerlessness, and a sense that your work doesn’t matter.”

Three distinct domains of burnout have been identified, including emotional exhaustion, depersonalization or cynicism, and low self-efficacy.

“Burnout was thought to be different from other mood disorders,” said Dr Back. “Burnout was felt to be a workplace issue, not necessarily something that generalized into your personal life. Over time, it has become clear that if you really are burned out, it does eventually spread to your personal life.”

Burnout Among Oncologists

Recent studies have shown that a majority of US physicians meet recognized criteria for burnout, including 45% of oncologists.1,2 These studies showed that 44% of oncologists had reached the point of emotional exhaustion or depersonalization. Paradoxically, 82% of the oncologists responding to the survey still expressed satisfaction with their career, and a similar proportion said they would make the same career choice if given a second chance.1,2

One potential clue to the origin of burnout among oncologists came from a recent study led by Tait D. Shanafelt, MD, Professor of Medicine, Hematology, and Consultant Physician, Mayo Clinic, Rochester, MN, who presented his study results.2 The results showed that only 33% of oncologists were satisfied with their work–life balance, declining to 25% of oncologists in academic settings.2

Expectations of patients and families may be another contributing factor in burnout, Dr Back suggested. A study of 449 primary care physicians revealed a common theme that included insistence on specific therapies and tests, and unrealistic expectations.3 A high proportion of “difficult patients” had a highly significant association (odds ratio, 12.2) with burnout.3

Recognizing Burnout

Burnout evolves differently and affects different domains of the syndrome in men and in women. A study of Dutch physicians showed that burnout in women initially manifested as emotional exhaustion. The affected individual feels worn out, a feeling that subsequently progresses to guilt and uncertainty about the quality of work.

“Feeling like everybody is difficult—that’s one of the signs of burnout,” said Dr Back.

In men, burnout tends to manifest as depersonalization. Starting with withdrawal, the syndrome progresses to feelings of being emotionally drained. The growing body of literature on burnout has identified at least 3 distinct subtypes of the condition.

  1. One subtype comprises healthcare professionals who become overloaded, work to exhaustion, and eventually “throw in the towel.” Dr Back said that this category likely comprises the largest proportion of professionals with burnout, although no data exist to support that view.
  2. A second category comprises people who are “underdeveloped,” and are no longer challenged by their work or profession. They gradually distance themselves from their work and become disengaged.
  3. A third category is “neglecting,” namely, people who have no real coping strategies for their situation. Over time, their work becomes drained of all meaning, and they lose sense of direction or purpose.
Burnout has consequences, all of which are potentially serious to individuals, systems, and patients, said Dr Shanafelt. Multiple studies have documented the consequences, which include decreased patient satisfaction and compliance, increased medical errors, decreased professionalism, increased turnover, and even serious personal repercussions for affected individuals, including suicidal ideation.

Managing Burnout

Research has identified 5 key drivers of burnout and satisfaction, including workload, efficiency, autonomy/flexibility, work–life integration, and finding meaning in work. To address these drivers, Dr Shanafelt suggested that much insight can be gained from the science of happiness.4

Happiness has 3 key components: pleasure, engagement, and meaning. Attaining an appropriate mix of all 3 components can afford a strong measure of prevention with respect to burnout and its adverse effects on the individual and the system.

Lessons learned from the study of flow theory also apply to prevention and management of burnout, Dr Shanafelt continued. Flow theory includes the concept of psychologic selection, whereby individuals preferentially cultivate a limited subset of activities, values, and personal interests.5 Optimal selection leads to “flow” within each individual, characterized by deep concentration, intrinsic motivation, and a sense of “having the stuff to meet challenges,” according to Dr Shanafelt.

Using a hypothetical surgeon as an illustration, Dr Shanafelt said the surgeon has removed hundreds of gallbladders over the course of a career. As time and experience pro­gress, the surgeon evolves from anxiety, born of inexperience and unfamiliar challenges, to a sense of boredom and disengagement, resulting from a well-developed skill set and a limited sense of challenge.

“This is the exact same person, doing the exact same professional task,” said Dr Shanafelt. “At one point in the career, this brings anxiety, at another point boredom, and at another point flow. What it speaks to is that you are going to have to reimagine and reinvent yourself over the course of a career. What motivated you 5 years ago or motivated you today is unlikely to sustain you through the rest of your career. You have to keep identifying what motivates you today.”

The ability to “optimize meaning” within a medical career has a key role in preventing burnout. An earlier study by Shanafelt and colleagues showed that physicians who spent less than 20% of their time engaged in what they considered the most meaningful career activity were almost twice as likely to exhibit signs of burnout.6

This 20% threshold appears to be a “critical mass” of sorts. Physicians who engaged in that meaningful activity 50% or 75% of the time were no happier than those who were engaged at the 20% level.


  1. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377-1385.
  2. Shanafelt TD, Gradishar WJ, Kosty M, et al. Burnout and career satisfaction among US oncologists. J Clin Oncol. 2014;32:678-686.
  3. An PG, Rabatin JS, Manwell LB, et al; for the MEMO Investigators. Burden of difficult encounters in primary care: data from the minimizing error, maximizing outcomes study. Arch Intern Med. 2009;169:410-414.
  4. Seligman ME, Parks AC, Steen T. A balanced psychology and a full life. Philos Trans R Soc Lond B Biol Sci. 2004;359:1379-1381.
  5. Massimini F, Delle Fave A. Individual development in a bio-cultural perspective. Am Psychol. 2000;55:24-33.
  6. Shanafelt TD, West CP, Sloan JA, et al. Career fit and burnout among academic faculty. Arch Intern Med. 2009;169:990-995.

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