Stress and burnout-a view from the couch

“Because of the kind of work that we do, no one in our field is immune to burnout,” says Walter F. Baile, MD, a professor of behavioral science and psychiatry at the University of Texas, MD Anderson Cancer Center.

Burnout is a consequence of stress. It may result in clinicians losing their sense of accomplishment; they deteriorate from openness to self-protection and don’t feel useful. Sometimes that can create an identity crisis, Baile said at the 2010 Supportive Oncology Conference in Chicago.

Because much of what those who treat cancer do is on an emotional level, coping requires skill in reflecting on the impact on one’s own morale. The Maslach Burnout Inventory, long recognized as the leading indicator of burnout, gives these dimensions of the problem: emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment.

In one of the first studies of burnout among U.S. oncologists in 1991 (Whippen and Canellos), 56% responded they were burned out. A Barrett and Yates study in 2002 found that 37% of oncology nurses reported experiencing high levels of emotional exhaustion. Consequences include decreased job satisfaction, absenteeism, high turnover, psychiatric morbidity, and negative carryover into family life. It also may have implications for patient care because burnout also leads clinicians to make medication errors, neglect to perform diagnostic tests and provide incomplete information to patients, Baile said.

Factors on which stress feeds are rooted in the very nature of the job, Baile notes: “There’s responsibility for the lives of others, facing problems which seem to have no solutions, thinking we’re indispensable, working in an environment where no mistakes are allowed, and the pressures of combining office pressures and academic pursuits. Self- sacrifice is part of the culture. No wonder there is burnout in oncology and medicine in general.”

Preventing burnout must come on two levels, Baile says. First, strategies organizations can adopt:

--Review workload and administrative responsibilities

--Attend to the work environment, making changes even as small as ambient light

--Encourage input into the practice

--Develop programs to enhance communication and deepen relationships with patients. This also includes helping doctors recognize when empathy has turned to sympathy.

--Encourage leave time.

“We are the only country in the world that does not mandate paid holidays for employees,” Baile says, despite research that shows employee retention and productivity goes up with the number of paid vacation days. In addition, only about one-third of employed U.S. adults use all the vacation time they have.

An example of a positive culture change in terms of burnout has been reframing medical errors not as a disgrace—but as an opportunity to look at why something went wrong, Baile said. Studies have found common elements among oncologists who rate their well-being as high, Baile said. They strove for balance in their lives; they had strategies for coping with end-of-life issues and patients’ deaths; they had extensive use of recreation, hobbies and exercise.

Baile gives these strategies for reducing burnout on a personal level:

--Create a calendar and schedule time for exercise

--Learn your limits—take time away, have quiet time to process your day

--Nurture your relationships with friends and family

--Debrief with colleagues after difficult cases

--Do a self-assessment to see whether what you value in your life is what you’re focusing on. Rate the importance of family, work, friends, hobbies, etc., from 1-5 in one column and your current level of focus and energy on those areas in the second column to see where the deficits are. If your family is most important to you and you’re neglecting it, that’s a deficit you need to address. Ask yourself which area is most out of balance, what is easiest to fix and what steps can I take right now?

--Find the part of your work that means the most to you and become an expert in that area.

-- Acknowledge the importance of your role as a healer.

“If only I could get my medical oncology colleagues to understand that being there with a patient and holding their hand is a very powerful therapy in the eyes of a patient or listening without interrupting or telling the patient that they’re doing a great job in the face of all the chemotherapy and other treatments that they’re doing. These are the things that patients really value from us, especially when there’s no more to be done medically.”