Introduction
Burnout of medical practitioners in oncology is a worldwide phenomenon.[1],[2],[3],[4] Among hospital-based consultants in the United Kingdom, decrease in job satisfaction
went hand in hand with increase in job-related stress. The same study compared different
specialties over time, and the authors concluded that clinical and surgical oncologists
were at an increased risk of burnout.[5] This could be because of a plethora of reasons such as having to tackle difficult-to-treat
diseases, poor outcome of cancer in many instances,[6] frequent dealings with palliation and end-of-life scenarios,[4] and lack of training in handling emotional aspects of medical care.[7] Most of the studies on burnout of medical practitioners have been carried out in
the West. Few of the publications on burnout and work–life balance of doctors from
Asia are more from affluent countries such as Singapore[4] and Japan.[8] Very little literature exists on burnout in oncologists from the developing countries,
which ironically grapples with the twin problem of larger cancer burden and lower
doctor–patient ratio.
Depression and anxiety have been studied along with burnout in some studies. A study
found the prevalence of psychiatric morbidity to be 27% among doctors.[1] A nationwide retrospective cohort study from the United Kingdom covering the period
between 1979 and 1995 found that female medical practitioners had higher suicide rate
than the general population. Male doctors, on the other hand, had lower suicide rate
than the general population.[9] Burnout and psychiatric morbidity in doctors and more specifically those working
in the field of oncology need exploration in the context of gender and work–life balance.
India records more than a million new cancer patients every year.[10] To the best of our knowledge, none of the studies on burnout from India[11],[12],[13] have focused on oncology clinicians. Of the studies on oncology clinicians conducted
in other parts of the world, none has followed mixed methods approach of investigation
where qualitative findings are juxtaposed with quantitative findings to get an insider's
perspective.
Methods
We studied burnout and its associations using mixed methods of inquiry intertwining
qualitative and quantitative research methodology in a developing country setting.
The study was conducted after obtaining approval from the institutional ethics committee
(EC/TMC/49/15). Written informed consent was obtained from all participants.
Research team
The core research team consisted of a consultant psycho-oncologist, two psycho-oncology
fellows, a staff health physician, a consultant surgical oncologist, an epidemiologist
with specific expertise in qualitative research, and two visiting social science interns.
All members of the research team had previously undergone communication skills training.
Two senior members of the team (SSD and SP) had independently led and published qualitative
and mixed methods research while all the other members had undergone training in research
methods.
Setting
The subspecialties of oncology including surgery, radiotherapy, medical oncology,
clinical hematology, nuclear medicine, radiodiagnosis, palliative medicine as well
as laboratory-based departments such as hematology, biochemistry, histopathology,
radiodiagnosis, and clinical microbiology of a tertiary care hospital comprised the
study setting. The researchers who undertook quantitative and qualitative interviews
were not part of any of the clinical teams or the hospital where the study was conducted.
This made them particularly suitable as interviewers, as most doctors could open up
easily to them.
Eligibility criteria
Doctors who had been employed in the hospital for at least 1 month were eligible to
participate in the study. The cutoff of 1 month was chosen based on the assumption
that, in the 1st month of a new job, the doctors may not be exposed adequately to
work-related stresses. The only exclusion criterion was that of a participant who
the researcher felt extremely vulnerable to be interviewed. None of the respondents
approached for participation in the study met the exclusion criteria.
Recruitment method
A comprehensive list of all doctors employed by the study hospital was obtained from
the department of human resources. The researchers approached potential participants
individually. A record of the specialties of doctors who refused to participate was
maintained without personal identifiers so that any systematic refusal could be investigated.
Data collection method
The qualitative part of the study adhered to the COREC guidelines for research.[14] Participants were interviewed privately in their own offices, at their convenience,
so as to make them comfortable in discussing sensitive issues related to well-being,
work–life balance, and burnout. Following a sequential mixed methods design, a subsample
of respondents was purposively chosen for qualitative interviews from those who completed
the quantitative structured interview. All qualitative interviews were recorded and
transcribed verbatim by the researchers. Measures were taken to maintain confidentiality
of participants and around the responses obtained.
Data collection instruments
Quantitative data
A predesigned structured questionnaire capturing demographic and occupational information
was used. Other sections in the questionnaire had items to quantify burnout and to
screen for affective symptoms. The outcome variable of interest was emotional exhaustion,
and the instrument used to quantify this was Maslach Burnout Inventory (MBI).
The MBI is a 22-item self-administered inventory used for measuring burnout and has
been used globally to quantify burnout in staff across various settings.[15] Following scoring, the questionnaire generates three subscales, namely emotional
exhaustion, depersonalization, and professional accomplishment. All the three subscale
scores were divided into low, moderate, and high based on predetermined cutoff scores
provided by the authors. Emotional exhaustion was kept at the focus of the current
exploration as sufficient number of respondents was available for analysis following
classification on intensity score.
While sociodemographic variables generated information on factors that could be associated
with emotional exhaustion, Patient Health Questionnaire-4 (PHQ-4) score was another area of exploration. The PHQ-4 is a 4-item ultrabrief screening
questionnaire validated for detecting depression and anxiety in a population who do
not already have a psychiatric diagnosis.[16] Authors of the PHQ-4 have proposed that a score of 0–2 correspond to possible noncases
and those who score 3 or more as possible cases. In the current study, same cutoff
for defining a case (respondents scoring 3 or more on the PHQ-4) was used.
Qualitative data
The interviewers followed a predetermined series of cues and prompts while conducting
in-depth interviews. The cues were related to what was perceived to be stressful while
working as a doctor in general and working specifically in a cancer hospital and how
doctors maintained a work–life balance. Qualitative data analysis and data collection
went on concurrently to incorporate newly emerging themes from earlier interviews
until data saturation was achieved.
Data analysis
The subscale scores on the MBI were converted to categorical variables based on internationally
accepted cutoffs as suggested by the authors of the MBI. Following tests of normality
of distribution of associated factors, nonparametric statistical tests were used.
Univariate analysis was conducted to explore the association of variables across the
two groups of doctors reporting different levels of emotional exhaustion. Multivariate
logistic regression was conducted with emotional exhaustion as the dependent variable.
Factors which were significantly associated (P < 0.05) with emotional exhaustion in univariate analysis were entered as independent
variables in the multivariate regression model.
Qualitative in-depth interviews were transcribed verbatim, and transcripts were anonymized.
All interviews were coded by two independent researchers in the team. A senior researcher
along with the two coders reviewed the codes and helped to sort out any differences
as qualitative analysis progressed. The various steps of qualitative data analysis
involved (a) generating codes using the principles of thematic analysis, (b) charting
the data, (c) data synthesis, (d) formulation of basic themes, and (e) developing
global themes. Basic and global themes were generated by the method of thematic analysis
as described by Braun and Clarke.[17]
Results
Respondent profile
One hundred and thirty-one of the 150 doctors (87.3%) employed in the hospital were
eligible to be recruited in our study and were invited to participate. Of those approached,
114 doctors (114/131; 87%) consented for participation. Those who refused (17/131;
13%) to participate were evenly distributed across specialties (clinical/medical oncology
9, surgical oncology 5, and laboratory/diagnostic specialties 3). The median age of
the doctors recruited was 34.5 years (interquartile range [IQR] 31–40; minimum 28
years and maximum 60 years). The median number of years that the study participants
had practiced as a doctor and as an oncologist was, respectively, 12 years (IQR 7.75–15,
minimum of 0.25 year to a maximum of 38 years) and 4 years (IQR 2–6.25, minimum of
1 year to a maximum of 33 years). Only 6 (6/114, 5%) doctors had worked < 6 months
in the field of oncology. This is because, being a newly built hospital, many doctors
who joined at middle and senior levels already had several years of experience in
the field of oncology. The detailed characteristics of the study participants are
described in [Table 1]. Twenty-eight doctors across specialties and belonging to different age groups were
purposively selected for qualitative in-depth interviews.
Table 1
Respondent characteristics (n=114)
|
Attributes
|
n (%)
|
|
Age (years)
|
|
25-29
|
13 (11)
|
|
30-34
|
44 (39)
|
|
35-39
|
24 (21)
|
|
40-44
|
13 (11)
|
|
45-49
|
8 (7)
|
|
>50
|
12 (11)
|
|
Gender
|
|
Female
|
38 (31.4)
|
|
Male
|
76 (66.67)
|
|
Specialties
|
|
Surgical oncology-related specialties
|
47 (41.2)
|
|
Medical/radiation oncology-related specialties
|
37 (32.5)
|
|
Diagnostics and laboratory-based specialties
|
30 (26.3)
|
|
Marital status
|
|
Single
|
18 (15.8)
|
|
Married/in a relationship
|
96 (84.2)
|
|
Life partner’s professional status
|
|
Partner is a doctor
|
62 (54.4)
|
|
Partner is a nondoctor
|
34 (29.8)
|
|
Currently not a having partner
|
18 (15.8)
|
|
Having children
|
|
Yes
|
62 (54.4)
|
|
No
|
52 (45.6)
|
Depression and anxiety in doctors as assessed on the Patient Health Questionnaire-4
Majority of the doctors did not qualify as a PHQ case, and the data were positively
skewed. A total of 45 (45/114; 39.5%) doctors qualified as cases (for anxiety or depression
combined) and 69 (69/114; 60.5%) were noncases as per the PHQ-4 cutoff described in
methodology.
Quantitative results on burnout of doctors
The subscale scores of the MBI were calculated for the study participants. The distribution
of subscale scores on MBI, namely emotional exhaustion, depersonalization, and sense
of personal accomplishment, is shown in [Table 2].
Table 2
Maslach Burnout Inventory subscale scores
|
Median (IQR)
|
Range
|
|
MBI – Maslach Burnout Inventory; IQR – Interquartile range
|
|
MBI (emotional exhaustion)
|
15.5 (1.75, 23.25)
|
0-50
|
|
MBI (depersonalization)
|
4 (2, 7)
|
0-21
|
|
MBI (personal accomplishment) accomplishment
|
36 (30, 42)
|
0-48
|
Factors associated with emotional exhaustion
Many doctors experienced high levels of emotional exhaustion (45/114; 39.4%), and
factors associated with it are illustrated in [Table 3]. The doctors who participated in some form of sports had lower levels of emotional
exhaustion. Emotional exhaustion was associated with perceptions of the job being
demanding and a sense of having less time than what is available to do justice to
the job. Increased emotional exhaustion was also associated with various symptoms
of reduced sleep, reduced appetite, increased fatigue, headache, and mental exhaustion.
Doctors with high levels of emotional exhaustion perceived that their work environment
was less sensitive toward employees, felt that they were not respected in their role,
and were more likely to be depressed. Being a female was associated with higher levels
of emotional exhaustion as compared to their male counterparts in univariate analysis.
Younger age, lesser number of years being a doctor, and lesser number of years in
the field of oncology were other factors associated with emotional exhaustion.
Table 3
Association of emotional exhaustion: Univariate analysis
|
Variable
|
Emotional exhaustion
|
P
|
OR
|
95% CI of OR
|
|
Low (n=49; 60.5%)
|
Intermediate/High (n=45; 39.5%)
|
|
PHQ – Patient Health Questionnaire; OR – Odds ratio; CI – Confidence interval
|
|
Age
|
|
≤34 years
|
29
|
28
|
0.04
|
2.27
|
1.05-4.9
|
|
≥34 years
|
40
|
17
|
|
|
|
|
Gender
|
|
Male
|
51
|
25
|
0.04
|
2.27
|
1.02-5.03
|
|
Female
|
18
|
20
|
|
|
|
|
Marital status
|
|
Single
|
8
|
10
|
0.13
|
2.18
|
0.79-6.03
|
|
Married/in a relationship
|
61
|
35
|
|
|
|
|
Children (n=92)
|
|
Married with children
|
18
|
13
|
0.39
|
1.48
|
0.61-3.6
|
|
Married without children
|
41
|
20
|
|
|
|
|
Frequency of participation in sports
|
|
None
|
36
|
32
|
0.02
|
0.59
|
0.38-0.92
|
|
Occasional
|
5
|
5
|
|
|
|
|
More than once a week
|
28
|
8
|
|
|
|
|
Number of years of experience as a doctor (n=113)
|
|
<12 years
|
28
|
27
|
0.04
|
2.12
|
1.02-4.72
|
|
≥12 years
|
41
|
17
|
|
|
|
|
Number of years of experience as an oncologist (n=113)
|
|
<4 years
|
28
|
27
|
0.04
|
2.12
|
1.02-4.72
|
|
≥4 years
|
41
|
17
|
|
|
|
|
Number of years of experience in the specialty (n= 111)
|
|
<6 years
|
26
|
29
|
0.01
|
3
|
1.37-6.54
|
|
≥6 years
|
41
|
15
|
|
|
|
|
Job satisfaction
|
|
8-10
|
44
|
13
|
<0.001
|
4.33
|
1.9-9.7
|
|
0-7
|
24
|
32
|
|
|
|
|
Work pressure
|
|
8-10
|
15
|
25
|
<0.001
|
4.5
|
1.98-10.22
|
|
0-7
|
54
|
20
|
|
|
|
|
Activities I perform demand more time than I have in a work day
|
|
I feel this less than once in a week
|
28
|
4
|
0.001
|
6.99
|
2.25-21.7
|
|
I feel this more than or at least once a week
|
41
|
41
|
|
|
|
|
I feel I can control over procedures and care that I am assigned to at work
|
|
I feel this less than once in a week
|
61
|
40
|
0.94
|
0.95
|
0.29-3.12
|
|
I feel this more than or at least once a week
|
8
|
5
|
|
|
|
|
The place where I work rewards and acknowledges accurate diagnosis, care, and procedures
performed by employees
|
|
I feel this less than once in a week
|
44
|
19
|
0.25
|
2.41
|
1.12-5.19
|
|
I feel this more than or at least once a week
|
25
|
26
|
|
|
|
|
I notice that the place I work is sensitive to employees, valuing and acknowledging
the work developed. It invests in career and encourages professional development
|
|
I feel this less than once in a week
|
35
|
13
|
0.02
|
2.53
|
1.14-5.63
|
|
I feel this more than or at least once a week
|
34
|
32
|
|
|
|
|
I clearly see that there is respect in the relationships (among work teams and coordinators)
in my work place
|
|
I feel this less than once in a week
|
55
|
28
|
0.04
|
2.38
|
1.03-5.53
|
|
I feel this more than or at least once a week
|
14
|
17
|
|
|
|
|
In my work, I can perform tasks that I consider important
|
|
I feel this less than once in a week
|
64
|
34
|
0.01
|
4.14
|
1.33-12.89
|
|
I feel this more than or at least once a week
|
5
|
11
|
|
|
|
|
Frequency of headaches
|
|
Less than once in a week
|
63
|
31
|
0.004
|
4.74
|
1.66-13.53
|
|
More than or at least once a week
|
6
|
14
|
|
|
|
|
Changes in appetite (less/excess)
|
|
I feel this less than once in a week
|
64
|
32
|
0.004
|
5.2
|
1.7-15.86
|
|
I feel this more than or at least once a week
|
5
|
13
|
|
|
|
|
Frequency of sleep difficulties
|
|
Less than once in a week
|
64
|
36
|
0.05
|
3.2
|
0.996-10.28
|
|
More than or at least once a week
|
5
|
9
|
|
|
|
|
Mental exhaustion
|
|
I feel this less than once in a week
|
56
|
16
|
<0.001
|
7.81
|
3.31-18.42
|
|
I feel this more than or at least once a week
|
13
|
29
|
|
|
|
|
Time available for self
|
|
I feel this less than once in a week
|
34
|
10
|
0.005
|
3.40
|
1.46-7.93
|
|
I feel this more than or at least once a week
|
35
|
35
|
|
|
|
|
Fatigue
|
|
≥ A week
|
48
|
16
|
<0.001
|
4.14
|
1.87-9.19
|
|
≥ A week
|
21
|
29
|
|
|
|
|
Increased substance use
|
|
I feel this less than once in a week
|
68
|
42
|
0.18
|
4.85
|
0.49-48.06
|
|
I feel this more than or at least once a week
|
1
|
3
|
|
|
|
|
Difficulties in memory and concentration
|
|
I feel this less than once in a week
|
63
|
34
|
0.03
|
3.40
|
1.15-9.99
|
|
I feel this more than or at least once a week
|
6
|
11
|
|
|
|
|
I think I have lost my sense of humor
|
|
I feel this less than once in a week
|
62
|
30
|
0.003
|
4.43
|
1.63-12.01
|
|
I feel this more than or at least once a week
|
7
|
15
|
|
|
|
|
PHQ anxiety
|
|
Case
|
9
|
9
|
0.3
|
1.67
|
0.61-4.6
|
|
Noncase
|
60
|
36
|
|
|
|
While conducting multivariate analysis, we selected only six variables for adjustment
in the model including age, gender, frequency of participation in sports, job satisfaction,
work pressure, and total PHQ score. The variables on symptoms such as having headaches,
having less or excessive appetite, difficulties with sleep, mental exhaustion, having
reduced time for self, increased fatigue, increased substance use, difficulties in
memory and concentration, and decreased sense of humor were not included in the model
as we felt that they were manifestations of emotional exhaustion itself. In the multivariate
model, we found that being female, being a doctor who perceived high levels of work
pressure, a doctor who had reduced sense of job satisfaction, and those who qualified
as a case as per the PHQ-4 were independently associated with high levels of emotional
exhaustion [Table 4].
Table 4
Associations of emotional exhaustion: Multivariate analysis
|
Variable
|
Emotional exhaustion
|
P
|
AOR
|
95% CI
|
|
Low (n=49; 60.5%)
|
Intermediate/High (n=45; 39.5%)
|
|
AOR – Adjusted odds ratio; CI – Confidence interval
|
|
Sex
|
|
≤34 years
|
29
|
28
|
0.08
|
2.33
|
0.9-6.06
|
|
>34 years
|
40
|
17
|
|
|
|
|
Sex
|
|
Male
|
51
|
25
|
0.002
|
3.4
|
1.2-9.5
|
|
Female
|
18
|
20
|
|
|
|
|
Frequency of participation in sports
|
|
None
|
36
|
32
|
0.3
|
0.75
|
0.43-1.3
|
|
Occasional
|
5
|
5
|
|
|
|
|
Once a week or more
|
28
|
8
|
|
|
|
|
Sex
|
|
8-10
|
44
|
13
|
0.009
|
3.56
|
1.37-9.25
|
|
0-7
|
24
|
32
|
|
|
|
|
Sex
|
|
8-10
|
15
|
25
|
0.001
|
5.39
|
2.01-14.47
|
|
0-7
|
54
|
20
|
|
|
|
|
Sex
|
|
Case
|
18
|
27
|
0.03
|
2.89
|
1.11-7.46
|
|
Noncase
|
51
|
18
|
|
|
|
Perceptions of cancer clinicians about their job
Workplace conditions and stress
Almost all the participants, irrespective of gender, acknowledged that working as
a cancer clinician could be stressful. Other sources of stress consisted of “long
working hours” and “inadequate leave at workplace.” The following verbatim quotes
capture such aspects:
“I think work is the main stress” (Male, 32 years).
“If you know that you will have to do 3 emergency duties in a week for three consecutive
weeks, you get only 2 days free in that whole period. That affects your work–life
balance” (Male, 45 years).
“ Not having adequate leaves puts me under a lot of stress” (Female, 32 years).
One doctor mentioned that worries about future career prospects contributed to the
stress:
“My job is not permanent. This is not hampering our day-to-day work but it is stressful
when we think of the future” (Male, 40 years).
Patient condition, outcome, and stress
The participants highlighted various factors as the sources of stress. These included
“exhausting physical conditions of patients,” “not being able to cure many patients,”
and “difficulties in engaging in end-of-life discussion with patients.”
“Sometimes we need to treat people with difficult conditions. That can be stressful”
(Male, 37 years).
“We do not have regular patients with minor ailments who get admitted to this hospital.
As a result, we do not do surgeries like appendicectomy. All of our patients are already
metabolically exhausted. They are fighting a long battle. They are physiologically
very weak. And then, they have to undergo long surgeries. We have to prepare the patient
for that and keep the patient in good shape throughout the surgery” (Male, 36 years).
“I think it is most difficult to counsel a fellow man that he is going to die”(Male,
38 years).
Social and psychological challenges
A few doctors indicated that counseling patients about expensive treatment options
in oncology could be emotionally draining, especially when patients had limited financial
means and the clinician knew that the impact of funding the treatment could affect
the entire family for a foreseeable future. One of the doctors went on to clarify
that this could pose a moral dilemma to the clinician.
“Suppose we give some medications for next 3 months that costs around 5 lakh rupees
($7467). That may give the patient an additional life of 3 months. Some people sell
their homes (to get the money). They also express their difficulties when they go
through this. Yet they sell it in the hope that the person will live for another 3
months. This sort of situation is very special to oncology. This does not happen in
most other branches of medicine” (Male, 38 years).
One doctor even said that he sometimes identified with patient:
“I put myself there and I think to myself that this person has got the disease without
any risk factor. So I can also get this same disease” (Male, 38 years).
Job satisfaction
Stress was not the only theme emerging from the responses of the doctors. Both male
and female respondents highlighted the issue of satisfaction derived from the work
they were engaged in. Some male doctors perceived their role as challenging and at
the same time satisfying. Despite the stress and difficulties, one of the respondents
articulated a strong sense of professional accomplishment, and a senior clinician
described the fulfillment of working in a team comprising of junior doctors.
“I like my job. To be honest, I struggled a lot to reach this place that I am in now.
Earlier I had felt that I would never make it” (Male, 29 years).
“You get the chance to interact with young fellows and students and the opportunity
to “learn from the younger generation” (Male, 49 years).
“Honestly, I have never understood why anybody should be stressed. If you think that
the work that you do is more fun, then it's like looking after yourself. You know
there is some part of you which is quite happy doing that work” (Female, 54 years).
Work–life balance vis-a-vis gender
One male surgeon summarized how work in the hospital could intertwine with home life
at a very practical level. There was a clear gender division around how work–life
balance was perceived by doctors although both genders found it difficult to balance
responsibilities to the family with those of being a doctor.
“A surgeon's life revolves around patients, complications, and operations. So if I
do a good operation and patient is doing well in the ward I feel very good. However,
if the patient is not doing well then I carry this thought with me when I return home.
The thought stays in my mind and I worry that I may get called in at night. So my
family life is hampered a little bit in some way. My wife tells me that you're still
in the hospital” (Male, 40 years).
“Frankly, if you ask me, I don't have a work–life balance” (Male, 32 years).
“I can't say 100% but 50%–60%? When it comes to my personal life, there is a lot of
sacrifice” (Female, 32 years).
Several male doctors pointed out that they were heavily dependent on their partners
to take care of the family while they worked in the hospital:
“I take responsibility for my patients and for my home I am little careless, my wife
does everything” (Male, 32 years).
Only one female doctor specifically mentioned that her husband was supportive and
actually helped her out in domestic responsibilities. Female doctors, on the other
hand, had to juggle home and work:
“My husband shares a lot of work with me” (Female, 32 years)
“Yeah at home I have responsibilities. I have to be a mother, a wife, and I am a homemaker
also” (Female, 52 years).
Female participants discussed the impact of work much beyond work. Women perceived
a much larger field of responsibility beyond work and as a result, felt guilty and
stressed:
“I appreciate the fact that I come to work but if I had to rank my priorities, my
kid is still above work” (Female, 42 years).
“I would say it's just the time that you have to give (to family). You have to take
out time from your work. That gets a little tricky. I try to do that on a Friday sometime”
(Female, 38 years).
“It's difficult because I give a lot of time to my son for his studies. A growing
child needs his mom which can get difficult for me” (Female, 32 years).
“After work, I have to work at home to raise a 13 year old! To be an independent adult
is not easy” (Female, 42 years)
There was a difference how clinicians of different genders perceived division of time
available all through the week differently. Male respondents often demarcated weekdays
from weekends, but women tried to balance the totality of their existence with a smoother
blend of home with work.
“Weekends are there for the family. The weekdays are not there for the family” (Male,
40 years).
“I realized even if I am working excessive hours, it's that (gestures to indicate
a large amount) amount of work that is left behind (at work) at the end of the day,
so …………24 months ago, one evening I decided I would go home on time every day” (Female,
42 years).
“I try not to take my work home. When I leave, I won't say I switch off but I turn
the volume down.” (Female, 51 years).
Juxtaposition of qualitative and quantitative results
In the following section, we present juxtaposed quantitative and qualitative results
along with the proposed areas of interventions. The innermost circle of the diagram
[Figure 1] represents the quantitative results highlighting the association of emotional exhaustion
with increased work pressure, reduced job satisfaction, being female, and having increased
anxiety and depressive symptoms. The qualitative interviews brought out views (middle
circle) of doctors on three of the four above associations. While many clinicians
spoke about the job-related stresses, several of them found working in oncology to
be a deeply satisfying experience and parts of the job being unsatisfactory. Both
genders spoke about difficulties in maintaining work–life balance, but there were
some special aspects how women viewed the issue of stress and work–life balance. The
outermost circle captures some of the probable areas of interventions. We suggest
that hospitals have employee-friendly policies that promote psychological well-being
and a healthy work–life balance. Reduced working hours and flexible working hours
may help some staff. Cancer clinicians should be provided with opportunities to learn
communication skills to handle bad news situations so that these interactions are
not a source of undue stress for the patient or the clinician. Access to confidential
occupational mental health services to treat depression and other psychiatric conditions
in staff may help to identify and address problems early.
Figure 1: Diagram of juxtaposed findings of quantitative and qualitative data on emotional
exhaustion of doctors working in a oncology hospital and proposed areas of interventions
Discussion
Our study on the well-being and emotional exhaustion of oncology clinicians found
that being female, being a doctor who perceived high levels of work pressure, having
reduced sense of job satisfaction, and increased anxiety and/or depression scores
on PHQ were independently associated (P < 0.05) with higher levels of emotional exhaustion. However, qualitative investigational
approach helped us in obtaining clarity around the sources of stress and resulting
exhaustion. We further found that the stresses of working as an oncology clinician
could be related to the work pattern, unique patient characteristics in oncology,
and social and psychological processes at play during clinical contacts.
In oncology, as opposed to other branches of medicine, doctors often deal with life-limiting
conditions and difficult-to-treat ailments. We found that 39.5% of the doctors perceived
intermediate-to-high levels of emotional exhaustion, but we did not find a statistically
significant association of emotional exhaustion with the levels of seniority or number
of years working in the field of oncology. A longitudinal multicenter study from Brazil
found that emotional exhaustion and depersonalization increased over time as doctors
progressed through their oncology residency program.[18] Because ours is a cross-sectional study, it is not possible for us to comment on
the progression of symptoms of emotional exhaustion over time.
Although working in oncology was felt to be deeply satisfying by many clinicians,
there was a clear gender difference in the way work–life balance was perceived by
respondents in our study; women often charting out a larger field of responsibility
for themselves at home and work that blended seamlessly. This perceived larger field
of responsibility may result in dissatisfaction experienced among woman cancer clinicians.
Similarly, other studies have found that female doctors face more burnout inspite
of having more women in positions of leadership in health.[19],[20]
The current study has several strengths. A mixed methods design not only helped to
identify factors associated with higher levels of emotional exhaustion, but also to
shed light on some of the possible explanations for such associations. Interviewers
were all nonmedical and not part of the hospital staff, allowing the study respondents
to speak more freely. The doctors who participated in the qualitative and quantitative
parts of the study had varying degrees of experience and represented both genders
and mostly oncology specialties. The other strength was that the study was conducted
at a cancer center that had a dedicated full-time psycho-oncology team for occupational
mental health service, and this had likely played a role in destigmatizing mental
health among hospital staff, which was reflected in high participation (87%) from
the doctors approached for the study.
The weakness of our study was that it is of single-center design where stressors and
sources of support could be influenced by the particular organizational culture. Furthermore,
the cross-sectional nature of our investigation precluded taking any inference on
change in outcome variables over time and firmly establishing temporal relationship
of explanatory variables with the measured outcome. Having a cutoff of only 1 month
of working in the hospital, as an inclusion criteria, potentially could have recruited
participants who were not exposed to the stresses of working in a cancer hospital
long enough to face burnout or emotional exhaustion. However, most doctors finally
recruited had worked for a number of years in oncology.
We propose some areas of interventions that may help staff in cancer centers to prevent
and combat emotional exhaustion. Having employee-friendly policies that allow flexible
working pattern, reduction in long working hours, and access to training in communication
skills to break bad news and develop emotional resources to handle stress may have
an impact on the job satisfaction. Intervention development based on robust occupational
mental health policies and programs is indicated. Early identification and management
of affective disorders in oncology clinicians nurtured in an open organizational culture
will likely play a role in reducing emotional exhaustion.
