	A career in oncology can be a tremendously fulfilling and a meaningful venture. Oncologists care for the sick, advance medical science, and mentor the next generation of medical professionals. Despite the value and importance of these pursuits, an expanding body of literature reports that physicians are experiencing increased personal distress and decreased satisfaction with the medical practice.

 Unlike many other professionals, physicians often experience extreme fatigue and emotional exhaustion at early stages in their careers during medical school and residency. High rates of burnout and poor mental health among physicians can have a profound impact on patients’ quality of care and threatens the sustainability of the health care enterprise.

	What is burnout? Burnout is an emotional state seen in many individuals under constant pressure. It can be accompanied by a number of physical and behavioral signs and symptoms, such as exhaustion, perceived clinical ineffectiveness, impaired job performance, and lead to poor health, including hypertension, anxiety, and depression.

 The condition has been compared to a worker who has become separated or withdrawn from the original meaning and purpose of his work. Physicians experiencing burnout have been shown to have higher rates of divorce, suicide, job turnover, drug and alcohol abuse, and a shorter life expectancy.

	The risk of burnout increases in individuals who consistently experience work overload and a perceived lack of control. Simendinger et al suggested a three-degree model of burnout.

 The third, or most severe degree, is characterized by major physical and/or psychological breakdown including mental illness, heart attack, and ulcers.

 These individuals find their work unrewarding, believe they are treated unfairly, experience insufficient personal rewards (eg, loss of mentor support and intrinsic satisfaction) and are confronted with conflicting values.

	Several factors such as decreased autonomy, increased administrative tasks and paperwork, less time with patients, and difficulty balancing personal and professional responsibilities can contribute to burnout. Oncologists in academia may face additional stressors such as declining levels of funding to support their scientific research, and changes to the structure of fellowship that have increased their clinical responsibilities and decreased time for traditional academic pursuits such as research and education.

 As a result, physicians may not always have the opportunity to focus on the areas that they view as most personally meaningful.

	Interestingly, a study by Einhorn et al found that daily interaction with suffering and dying patients was not the greatest source of stress for oncologists.

 Rather, increased claims documentation requirements (such as those for Medicare) and bureaucratic hassles, which for many resulted in longer working hours, was the greatest concern among oncologists. Board certification may be modestly positively associated with satisfaction,and being a foreign medical graduate may be modestly negatively associated with satisfaction, although this is limited to few studies.

	Although burnout affects many individuals under constant pressure, oncologists in particular are frequently overloaded with the demands of their profession. The stressors of caring for ill patients, responding to the needs and questions of families, and experiencing limited treatment success and the constant loss of patients can exert an emotional toll on oncologists. In a 2003 survey, Allegra et al found that the rate of burnout among oncologists in the U.S. exceeded 60%.

 The seeds of burnout may be sown in residency and fellowship training, during which fatigue and emotional exhaustion are often the norm. By mid-career, the momentum of burnout may be subtly reinforced by the fact that your peers perceive you as a hard worker who places service to others before self-care. As a result, some physicians may deny major negative aspects of their work considering their commitment to become a well-trained medical oncologist.

	Fellows coping with the demands of their practice by working harder and longer may experience severe inefficiency, psychological impairment, and poor patient care. Fellows’ expectations are often their greatest source of stress, and few spend time reflecting on themselves or attending to their own needs. Even so, fellows might be reluctant to recognize or talk openly about psychological problems resulting from their professional experiences to avoid having a psychological diagnosis or a “weak fellow” label pinned on themselves. The nature of medical training can reinforce false beliefs in one’s immunity to difficulties and prevent recognition of serious psychological problems.

	When physicians suffer from burnout, negative effects on patient care and increased medical errors can result. A study by Isen et al found that third-year medical students with positively primed emotions and in whom positive affect had been induced arrived at an accurate diagnosis more efficiently and with greater curiosity and less disorganization.

 Given the potential human costs of medical mistakes, the emotional impact of actual or perceived errors can be devastating for oncologists. It’s well documented that doctors with burnout get sued more often.

 Learning how to prevent burnout, then, is of great importance.

	The intensity and scope of stressors facing physicians require healthy and successful coping strategies such as cultivating professional and personal relationships, maintaining control over in your career, and preserving your well-being.

 Nourishing close relationships is perhaps the most important aspect of your balancing act. Good relationships with patients, relatives, and staff help promote professional status esteem, intellectual stimulation, and good management and organizational structure. An adequate support system can be a powerful source of strength and resilience for physicians, who over time may feel isolated in their careers. Such loneliness can be especially pronounced for physicians who begin to feel down or burned-out. Through socialization and sharing their feelings with others, oncologists can also more readily recognize indicators of stress and burnout in colleagues. In addition to personal and professional relationships, support can be found through professional organizations and groups settings.

 A sense of autonomy and control over work is important to ensuring job satisfaction. Control over your schedule, including interventions to improve the flexibility and predictability of work hours is the most important predictor of work—life balance and burnout. While such a goal may seem impractical given the increasing demands on physicians, studies have suggested strategies for increasing one’s sense of control and improving resilience.

	A study by Jensen et al found that a main aspect of physician resilience was setting limits in both professional and personal arenas.

 Setting limits means being able to know when to say “no” to avoid over-commitment and achieve balance. This may mean prioritizing responsibilities, reducing working hours, changing the way you practice (eg, solo vs group practices), and scheduling time for exercise and relaxation. Since saying “no” inherently involves a certain degree of confrontation, physicians may be reluctant to deny requests from others and consequently find themselves drained or resentful. Giving yourself permission to set limits can markedly improve your professional satisfaction. Physicians with a positive coping strategy know how to organize their work, delegate job duties, and be realistic as to what can be accomplished with available time and resources.

	In a separate study by Dunn et al, interventions designed to increase physician control over the work environment, improve order in clinic functioning, and deepen the meaning physicians found in their work were examined.

 The study found that strategies such as soliciting physician input on the scheduling template and accommodating scheduling requests (eg, length of sessions) and other practice preferences (eg, case mix) contributed to decreasing their emotional exhaustion. The possibility for flexible working schedules via part-time and job share options can also be examined.

	Given the diversity of career opportunities for a medical oncologist, it is increasingly important that fellowship training provide the diverse experiences needed to make informed career choices. It’s essential to begin your fellowship with an open mind. Fortunately, post-fellowship career choices are usually reversible, and the opportunity exists to switch practice settings. Many oncologists have successfully transitioned from academia to nonacademia and vice versa, for example.

 Preventing burnout necessitates the promotion of your well-being. Physicians must be guided from the earliest years of training to cultivate methods of personal renewal, emotional self-awareness, connection with social support systems, and a sense of mastery and meaning in their work. Enjoying vacation or personal time will help alleviate burnout, while thinking positively can transform individuals for the better, making them healthier, more socially integrated, knowledgeable, effective, and resilient.

	A fellow’s greatest strength is a generally positive outlook. Thinking positively isn’t necessarily easy, but it’s essential. It would benefit fellows to realize early on that there are always going to be difficult situations during training; there is always going to be stress, and another fellow may get sick or need to leave and you will have to cover the call. It’s simply a part of life. Successful fellows dwell on the good times and not on the bad. At the end of each day, reflect on the positives and focus on what you learned. What went right and why?

	Mentorship programs are a valuable resource for supporting junior physicians in their career development and helping them navigate professional challenges.

 A mentor may also be able to detect dissatisfaction and help physicians reevaluate their interests and career paths. Opportunities for personal development, whether through medical education, personal hobbies, or sabbatical programs, can help physicians gain perspective and broaden their horizons. Spickard et al. emphasized that the principle “do no harm” is at the core of the medical profession and not incidental to physicians.

 As he put it, “doing no harm begins with one’s self.”

Mohamed Abdel Khalek, MD, is a clinical research fellow at Tulane Cancer Center in New Orleans, Louisiana. Emad Kandil, MD, FACS, is an assistant professor of surgery and medicine; adjunct assistant professor of otolaryngology; and chief of the endocrine surgery section in the division of endocrine and oncological surgery at Tulane University School of Medicine in New Orleans, Louisiana.

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A career in oncology can be a tremendously fulfilling and a meaningful venture. Oncologists care for the sick, advance medical science, and mentor the next generation of medical professionals.

Mohamed Abdel Khalek, MD

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