Abstract

Objectives: The aim of the current study was to explore the associations of emotional exhaustion in oncology clinicians and perceptions of doctors about their work–life balance in a developing country. Methods: The current study used quantitative semi-structured interviews and qualitative in-depth interviews to explore emotional exhaustion and burnout in doctors in a tertiary care cancer center. Sociodemographic details, Maslach Burnout Inventory, and Patient Health Questionnaire were used for the quantitative analysis. Results: Increased work pressure (adjusted odds ratio [AOR]: 5.39, 95% confidence interval [CI]: 2.01–14.47, P < 0 class="i" xss=removed>P < 0 class="i" xss=removed>P < 0 xss=removed class="b" xss=removed>Conclusion: Increased work pressure, reduced job satisfaction, and increased affective symptoms contribute to emotional exhaustion in oncology clinicians, and the risk increases especially in female doctors. Having gender-sensitive and employee-friendly policies will likely help in having a nurturing work environment.

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>

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 href="https://www.thieme-connect.com/products/ejournals/html/10.4103/ijmpo.ijmpo_168_17#TB_1" xss=removed>Table 1]. Twenty-eight doctors across specialties and belonging to different age groups were purposively selected for qualitative in-depth interviews..

| 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>

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.

1. Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM. Mental health of hospital consultants: The effects of stress and satisfaction at work. Lancet 1996; 347: 724-8
2. Shanafelt T, Dyrbye L. Oncologist burnout: Causes, consequences, and responses. J Clin Oncol 2012; 30: 1235-41
3. Leung J, Rioseco P, Munro P. Stress, satisfaction and burnout amongst Australian and New Zealand radiation oncologists. J Med Imaging Radiat Oncol 2015; 59: 115-24
4. Koh MY, Chong PH, Neo PS, Ong YJ, Yong WC, Ong WY. et al. Burnout, psychological morbidity and use of coping mechanisms among palliative care practitioners: A multi-centre cross-sectional study. Palliat Med 2015; 29: 633-42
5. Taylor C, Graham J, Potts HW, Richards MA, Ramirez AJ. Changes in mental health of UK hospital consultants since the mid-1990s. Lancet 2005; 366: 742-4
6. Buckman R. The invisible effects of therapeutic failure. Oncologist 2010; 15: 1370-2
7. Lyckholm L. Dealing with stress, burnout, and grief in the practice of oncology. Lancet Oncol 2001; 2: 750-5
8. Chatani Y, Nomura K, Ishiguro A, Jagsi R. Factors associated with attainment of specialty board qualifications and doctor of medical science degrees among Japanese female doctors. Acad Med 2016; 91: 1173-80
9. Hawton K, Clements A, Sakarovitch C, Simkin S, Deeks JJ. Suicide in doctors: A study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979-1995. J Epidemiol Community Health 2001; 55: 296-300
10. Mallath MK, Taylor DG, Badwe GK, Rath YK, Shanta V, Pramesh CS. et al. The growing burden of cancer in India: Epidemiology and social context. Lancet Oncol 2014; 15: e205-12
11. Jugale PV, Mallaiah P, Krishnamurthy A, Sangha R. Burnout and work engagement among dental practitioners in Bangalore city: A cross-sectional study. J Clin Diagn Res 2016; 10: ZC63-7
12. Pandey J, Singh M. Donning the mask: Effects of emotional labour strategies on burnout and job satisfaction in community healthcare. Health Policy Plan 2016; 31: 551-62
13. Ratnakaran B, Prabhakaran A, Karunakaran V. Prevalence of burnout and its correlates among residents in a tertiary medical center in Kerala, India: A cross-sectional study. J Postgrad Med 2016; 62: 157-61
14. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007; 19: 349-57
15. Maslach C, Jackson SE. Maslach Burnout Inventory. Palo Alto, California: Consulting Psychologist's Press; 1986.
16. Kroenke K, Spitzer RL, Williams JB, Löwe B. An ultra-brief screening scale for anxiety and depression: The PHQ-4. Psychosomatics 2009; 50: 613-21
17. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3: 77-101
18. Cubero DI, Fumis RR, de SáTH, Dettino A, Costa FO, Van EyllBM. et al. Burnout in medical oncology fellows: A prospective multicenter cohort study in Brazilian institutions. J Cancer Educ 2016; 31: 582-7
19. Győrffy Z, Dweik D, Girasek E. Reproductive health and burn-out among female physicians: Nationwide, representative study from Hungary. BMC Womens Health 2014; 14: 121
20. Downs JA, Reif LK, Hokororo A, Fitzgerald DW. Increasing women in leadership in global health. Acad Med 2014; 89: 1103-7

| 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|

1. Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM. Mental health of hospital consultants: The effects of stress and satisfaction at work. Lancet 1996; 347: 724-8
2. Shanafelt T, Dyrbye L. Oncologist burnout: Causes, consequences, and responses. J Clin Oncol 2012; 30: 1235-41
3. Leung J, Rioseco P, Munro P. Stress, satisfaction and burnout amongst Australian and New Zealand radiation oncologists. J Med Imaging Radiat Oncol 2015; 59: 115-24
4. Koh MY, Chong PH, Neo PS, Ong YJ, Yong WC, Ong WY. et al. Burnout, psychological morbidity and use of coping mechanisms among palliative care practitioners: A multi-centre cross-sectional study. Palliat Med 2015; 29: 633-42
5. Taylor C, Graham J, Potts HW, Richards MA, Ramirez AJ. Changes in mental health of UK hospital consultants since the mid-1990s. Lancet 2005; 366: 742-4
6. Buckman R. The invisible effects of therapeutic failure. Oncologist 2010; 15: 1370-2
7. Lyckholm L. Dealing with stress, burnout, and grief in the practice of oncology. Lancet Oncol 2001; 2: 750-5
8. Chatani Y, Nomura K, Ishiguro A, Jagsi R. Factors associated with attainment of specialty board qualifications and doctor of medical science degrees among Japanese female doctors. Acad Med 2016; 91: 1173-80
9. Hawton K, Clements A, Sakarovitch C, Simkin S, Deeks JJ. Suicide in doctors: A study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979-1995. J Epidemiol Community Health 2001; 55: 296-300
10. Mallath MK, Taylor DG, Badwe GK, Rath YK, Shanta V, Pramesh CS. et al. The growing burden of cancer in India: Epidemiology and social context. Lancet Oncol 2014; 15: e205-12
11. Jugale PV, Mallaiah P, Krishnamurthy A, Sangha R. Burnout and work engagement among dental practitioners in Bangalore city: A cross-sectional study. J Clin Diagn Res 2016; 10: ZC63-7
12. Pandey J, Singh M. Donning the mask: Effects of emotional labour strategies on burnout and job satisfaction in community healthcare. Health Policy Plan 2016; 31: 551-62
13. Ratnakaran B, Prabhakaran A, Karunakaran V. Prevalence of burnout and its correlates among residents in a tertiary medical center in Kerala, India: A cross-sectional study. J Postgrad Med 2016; 62: 157-61
14. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007; 19: 349-57
15. Maslach C, Jackson SE. Maslach Burnout Inventory. Palo Alto, California: Consulting Psychologist's Press; 1986.
16. Kroenke K, Spitzer RL, Williams JB, Löwe B. An ultra-brief screening scale for anxiety and depression: The PHQ-4. Psychosomatics 2009; 50: 613-21
17. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3: 77-101
18. Cubero DI, Fumis RR, de SáTH, Dettino A, Costa FO, Van EyllBM. et al. Burnout in medical oncology fellows: A prospective multicenter cohort study in Brazilian institutions. J Cancer Educ 2016; 31: 582-7
19. Győrffy Z, Dweik D, Girasek E. Reproductive health and burn-out among female physicians: Nationwide, representative study from Hungary. BMC Womens Health 2014; 14: 121
20. Downs JA, Reif LK, Hokororo A, Fitzgerald DW. Increasing women in leadership in global health. Acad Med 2014; 89: 1103-7