Managing Time & Avoiding Burnout in Oncology

ASCO — Insufficient time is a major source of stress and burnout in the practice of oncology, but oncologists can use a variety of strategies to increase their efficiency and get more satisfaction from their work and from life in general, according to an education session that took place at the 42nd Annual Meeting of the American Society of Clinical Oncology (education session 68).

Session chair Laurie J. Lyckholm, MD, of Virginia Commonwealth University, noted that four sources of stress and burnout in oncology come up repeatedly in the literature: not enough time for family and leisure activities, inability to keep up with current literature, not enough time to see patients the way one wants to, and dealing with telling bad news and with bad patient outcomes. Her informal straw poll of attendees suggested that more than half viewed "not enough time for family and leisure" as the most stressful aspect of their profession.

62% Report Burnout

In a recent survey of more than 1,700 US oncologists, 62% said they felt burned out. Moreover, 77% said that their burnout had been getting worse in recent years, said Tait D. Shanafelt, MD, of the Mayo Clinic College of Medicine.

Dr. Shanafelt noted that people drawn to medicine may be inherently at higher risk for burnout. One theory holds that physicians have a set of characteristics termed the "triad of compulsiveness," made up of doubt, guilt, and an exaggerated sense of responsibility. These traits are at the same time adaptive (eg, driving thoroughness and commitment to patients) and maladaptive (eg, making it difficult to relax and not feel responsible for things beyond one's control). In other words, he said, "Some of the traits that may make us good clinicians and devoted oncologists may be the very things that place us at risk of burnout."

Leading Stressors

Superimposed on these personality traits and characteristics are a number of work-related stressors, Dr. Shanafelt pointed out. In a survey of 241 oncologists in the North Central Cancer Treatment Group (NCCTG), the five leading stressors cited were patient load, balancing personal and professional life, keeping current with the literature, dealing with patient death and suffering, and delivering bad news to patients. "I think we can all look at these and identify that most of these things are fundamental tasks for us as oncologists," he commented.

When oncologists were asked which period of their career was most stressful, internship/residency was the leading response (35%), but current position was second (26%), suggesting that the perception that things will get better after training is not necessarily true, he noted. Lending further support to a concept of "life on hold" was the finding that 37% of oncologists said that looking forward to retirement was an essential wellness promotion strategy—a strategy equally common among respondents younger than and older than age 40.

Strategies for Relief

The good news, according to Dr. Shanafelt, is "increasing evidence that there are things that we can do to recover from burnout and to promote our own satisfaction with our career and our personal life." In the survey of NCCTG oncologists, common wellness promotion strategies reported by survey respondents overall included finding meaning in work (71%), having an approach/philosophy to dealing with death/end-of-life care (69%), protecting time away from work with spouse/family (66%), discussion with family or significant others (65%), and recreation/hobbies/exercise (59%). Most of these strategies were significantly more prevalent among oncologists reporting high overall quality of life than among those not.

Personal Perspectives

Heather S. White, MD, of Physicians East Hematology Oncology, Greenville, North Carolina, shared her perspective as a full-time medical oncologist in private practice and a mother, wife, daughter, and sister. Among the strategies she uses for coping on a daily basis, she said, are taking short breaks throughout the day and reading something nonmedical daily. "Set a stop point every day for busy work," she further advised. "The paperwork is never going to be finished."

Another measure that has helped has been learning to say no. "There are always opportunities to work more . . . But just draw the line," she said. She further noted that one simple change in patient care has been a dramatic time-saver: "I save 50% of dictating time if I do it immediately after seeing the patient."

Harold M. Chung, MD, of Virginia Commonwealth University, provided his perspective as an attending physician in a rapidly growing bone marrow transplantation unit that conducts research, as well as a husband and father. The birth of his daughter and a sensation of impending burnout, he explained, forced him to reevaluate. "I had to look at the important things in my life and figure out how I was going to balance all of that," he commented.

Taking the advice of a senior colleague who warned that in academics, physicians are constantly volunteered for projects, he began to set boundaries. In his day-to-day life, this has meant, for example, cutting in half the number of talks he attends and gives, and acting as principal investigator on fewer research protocols.

In terms of patient care, Dr. Chung said he now spends more time with patients upfront, taking notes for them during visits so that they have something concrete to refer to afterward. Another step that has helped things run more smoothly in the clinical setting, he noted, has been to convert the unit's transplantation protocols into worksheets that can be printed in individualized form for physicians, nurses, pharmacy, and patients—a change that has increased not only autonomy of the nursing staff, but also patient satisfaction. Dr. Chung also instituted a core lecture series for nursing staff on the unit. "I found that the more educated my nursing staff was, the fewer questions, the less confusion there was on the transplant unit," he said.

Turning to survival tactics at the personal level, Dr. Chung noted that his approach to managing the ever-increasing volume of e-mail is to read an e-mail message only once. "If I am not prepared to read and follow up on the e-mails, I won't sit down and bother at that time," he explained.

Another change he made was becoming a morning person. "It has increased my productivity because I am a lot brighter in the morning than I am at the end of a tiring long day," he said, adding that the new schedule allows him to see his family more. In addition, he now reads for work in the morning and for relaxation in the evening.

Stresses of Translational Research

Dr. Shanafelt, of the Mayo Clinic, shared his perspective as a translational scientist, as well as a husband, father, and brother. "The stresses of a translational science career are a bit different than a clinical career," he said. Although the challenge of maintaining grant funding is well recognized, other related stressors may not be. "I think that those of us who maintain a lab really are maintaining a small business," he said.

The other stresses the translational scientist faces include the small proportion of grants that are funded in general, stiff scientific competition, and keeping up with the literature—in both the clinical and research realms, Dr. Shanafelt said. The frequent travel required and the management of a laboratory budget and staff are also stressful.

Part of his approach to dealing with these stresses, Dr. Shanafelt said, has been to adopt a broader perspective. "I have had to redefine my view of success and make sure that when I am evaluating my success in my career, I do it on a more global level and look at my success both personally and professionally," he said.

Other strategies he uses include scheduling vacation with family immediately after intensive clinical or grant-writing periods; networking and collaborating with clinical colleagues in other specialties whom he can call on for their expertise; and consulting with administrators to learn skills for managing the lab.

Dr. Lyckholm referred attendees to the results of a survey that she and her co-presenters conducted among a convenience sample of oncologists in varied subspecialties, asking them for advice on identifying time sinks, improving efficiency, and avoiding burnout. Their responses (summarized in part in the Table), she noted, highlight the diversity of viewpoints and strategies among oncologists. For example, on the topic of whether e-mail is a help or hindrance, she said, "We asked 17 different oncologists and we really did get close to 17 different opinions."