Burnout among young European oncologists: a call for action

The practice of oncology is challenging but also often extremely rewarding. The article that accompanies this editorial, by the European Society for Medical Oncology Young Oncologists Committee, is yet another excellent demonstration of the difficulties that our profession faces on a daily basis [1.Banerjee S. Califano R. Corral J. et al.Professional burnout in European young oncologists: results of the European Society for Medical Oncology (ESMO) Young Oncologists Committee Burnout Survey.Ann Oncol. 2017; 28: 1590-1596Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar]. This large survey of 593 young oncologists, defined as those less than 40 years old, reported a staggering 71% rate of burnout amongst this population. Through linear multivariate regression analysis, the authors demonstrated that having no access to support services (P = 0.002), not having a good work-life balance (P < 0.0001), living alone (P = 0.024), and not having adequate vacation time (P = 0.002) were individual factors significantly associated with increased burnout scores. The fact that the geographic region in which the respondents live was also significantly associated with burnout is another important finding, with burnout rates highest in central Europe (84%) and Southeastern Europe (83%) and lowest in Northern Europe (52%). The authors even presented a statistical model to predict the risk of burnout in a given individual based on the significant factors in the multivariate analysis. Interpreting rates of burnout can be confusing, and logically most readers would be worried by the high rates reported in many studies [2.Medisauskaite A. Kamau C. Prevalence of oncologists in distress: Systematic review and meta-analysis.Psychooncology. 2017; Crossref PubMed Scopus (42) Google Scholar]. However some important aspects of the Maslach Burnout Inventory (MBI) [3.Maslach C. Jackson SE. The measurement of experienced burnout.J Organ Behav. 1981; 2: 99-113Crossref Scopus (6085) Google Scholar], the reference tool for measuring burnout, need to be explained. First of all, the MBI was developed in the 1980s by ranking 1104 United States physicians according to their high scores for each dimension of the score—emotional exhaustion (EE), depersonalization (DEP) and personal accomplishment (PA). The physicians belonging to the highest tertile for EE or DEP or the lowest tertile for PA were classified as being at high risk for burnout, and the cut-offs developed have remained unchanged since that time. Applying these cut-offs in a different population, the ‘high-risk’ population for each dimension of burnout, presumably would be about 33%. As an example, a recent meta-analysis reported a pooled rate of EE of 32% (95% confidence interval 28%–36%) among 17 published studies, strikingly close to the expected 33% [2.Medisauskaite A. Kamau C. Prevalence of oncologists in distress: Systematic review and meta-analysis.Psychooncology. 2017; Crossref PubMed Scopus (42) Google Scholar]. When analyzing MBI reports, readers should focus on differences across settings or countries, as has been done here, or on trends over time in addition to the absolute rates of burnout reported. Second, although burnout has been linked to numerous adverse situations, such as depression and suicide [4.Dyrbye L.N. Thomas M.R. Massie F.S. et al.Burnout and suicidal ideation among U.S. medical students.Ann Intern Med. 2008; 149: 334-341Crossref PubMed Scopus (857) Google Scholar], substance abuse [5.Blanchard P. Truchot D. Albiges-Sauvin L. et al.Prevalence and causes of burnout amongst oncology residents: a comprehensive nationwide cross-sectional study.Eur J Cancer. 2010; 46: 2708-2715Abstract Full Text Full Text PDF PubMed Scopus (156) Google Scholar], medical errors [5.Blanchard P. Truchot D. Albiges-Sauvin L. et al.Prevalence and causes of burnout amongst oncology residents: a comprehensive nationwide cross-sectional study.Eur J Cancer. 2010; 46: 2708-2715Abstract Full Text Full Text PDF PubMed Scopus (156) Google Scholar] or plans to retire early or change specialty [5.Blanchard P. Truchot D. Albiges-Sauvin L. et al.Prevalence and causes of burnout amongst oncology residents: a comprehensive nationwide cross-sectional study.Eur J Cancer. 2010; 46: 2708-2715Abstract Full Text Full Text PDF PubMed Scopus (156) Google Scholar, 6.Shanafelt T.D. Balch C.M. Bechamps G. et al.Burnout and medical errors among American surgeons.Ann Surg. 2010; 251: 995-1000Crossref PubMed Scopus (1162) Google Scholar], among others, burnout is a reflection of work-related distress, not a psychiatric disease. It is a reversible state that can pave the way to more serious or medically defined conditions. Third, the cut-offs are based on the development cohort, a group of physicians in California in the 1980s, and may not be valid in diverse settings, such as the 40 different countries analyzed in the present report. This is why the most important analysis in the article by Banerjee and colleagues is the one based on a multivariate linear regression analysis, which aims at identifying the factors that significantly influence the score for each subdomain, rather than only whether the ‘high tertile cut-off’ is crossed. There are limitations to this work, most of which are acknowledged in the discussion. First, owing to the mode of distribution of the survey, it is not possible to estimate the response rate, which carries the risk of reporting bias if the response rate had been low. Second, as stated above, the cut-offs published by Maslach and Jackson might not be valid in all of the countries represented in this report. There are clear differences in healthcare systems, availability of in-hospital support, and societal organization across the different European countries that could affect MBI scores and burnout rates, not to mention cultural differences that could affect the reporting of emotions or personal distress. Third, burnout is not a psychiatric disease; it would have been great if the authors had included short validated questionnaires on issues such as depression, suicidal ideation, or anxiety, for instance. Fourth, it is sometimes difficult to distinguish causes and consequences. As an example, when authors mention that ‘EE, DEP and PA scores were all significantly affected by not having a good work-life balance (P < 0.0001)’, that reflects more a statistical association than a potential causal relationship. Last, because of the cross-sectional design, it cannot be determined whether the high rates observed today were the result of a regular increase over time, or have been somewhat constant and are more a reflection of the status of young oncologists. Increasing trends of burnout have been noted in several medical specialties, as shown by annual Medscape studies [7.Physician Lifestyles – Linking to Burnout: A Medscape Survey. http://www.medscape.com/features/slideshow/lifestyle/2013/public#2 (20 May 2017, date last accessed).Google Scholar, 8.Medscape Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout. http://www.medscape.com/features/slideshow/lifestyle/2017/overview#page=2 (20 May 2017, date last accessed).Google Scholar], but it remains unclear whether this is due to increased stressors or more openness toward the issue. That being said, the authors are to be commended for their excellent work and important findings. We could not agree more that ‘a significant step in tackling burnout is the awareness of the extent of the problem in the oncology profession’. Burnout is a reversible state that can lead to very serious consequences, both for the affected individual and for those the individual cares for [4.Dyrbye L.N. Thomas M.R. Massie F.S. et al.Burnout and suicidal ideation among U.S. medical students.Ann Intern Med. 2008; 149: 334-341Crossref PubMed Scopus (857) Google Scholar, 6.Shanafelt T.D. Balch C.M. Bechamps G. et al.Burnout and medical errors among American surgeons.Ann Surg. 2010; 251: 995-1000Crossref PubMed Scopus (1162) Google Scholar]. Recognizing distress among our colleagues, especially the youngest ones, is our role. The fact that the existence of support within the hospitals was associated with reduced rates of burnout in the present study is an important call for hospital administrations and leadership to implement such structures for the benefit of all—the affected individuals, their teams, the whole institution, and of course, our patients. To do that, a positive, non-stigmatizing culture that encourages professionals to seek help must be put in place [9.Devi S. Doctors in distress.Lancet. 2011; 377: 454-455Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar]. This is especially important for younger doctors, who can experience their work-related difficulties as a personal weakness, when they are, in reality, the result of a multifactorial phenomenon in which factors related to patients, workplace, and management are key and can and should be improved. None declared.